Provider Demographics
NPI:1154414498
Name:BRINKERHOFF, PAUL W (CP)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:BRINKERHOFF
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-3106
Mailing Address - Country:US
Mailing Address - Phone:435-725-0999
Mailing Address - Fax:
Practice Address - Street 1:59 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-3106
Practice Address - Country:US
Practice Address - Phone:435-725-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870536042008Medicaid
UT87053604202001OtherBXBS
UT0966860001Medicare NSC