Provider Demographics
NPI:1386719003
Name:LONDON, MATT J (MPT)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:J
Last Name:LONDON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5997 S 200 E
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-573-7561
Mailing Address - Fax:
Practice Address - Street 1:6246 S REDWOOD RD
Practice Address - Street 2:BENNION CARE CENTER
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84123
Practice Address - Country:US
Practice Address - Phone:801-969-1420
Practice Address - Fax:801-955-2540
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD3244Medicaid