Provider Demographics
NPI:1154980852
Name:ON THE GO PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:ON THE GO PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUVALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:801-505-0716
Mailing Address - Street 1:2507 S 300 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2908
Mailing Address - Country:US
Mailing Address - Phone:801-505-0716
Mailing Address - Fax:
Practice Address - Street 1:2507 S 300 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2908
Practice Address - Country:US
Practice Address - Phone:801-505-0716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty