Provider Demographics
NPI:1427217405
Name:WASATCH PHYSICAL THERAPY AND REHABILATION CENTER
Entity type:Organization
Organization Name:WASATCH PHYSICAL THERAPY AND REHABILATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-713-0606
Mailing Address - Street 1:5323 WOODROW ST STE 204
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5852
Mailing Address - Country:US
Mailing Address - Phone:801-713-0610
Mailing Address - Fax:801-713-0613
Practice Address - Street 1:5323 WOODROW ST STE 204
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-5852
Practice Address - Country:US
Practice Address - Phone:801-713-0610
Practice Address - Fax:801-713-0613
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UTAH BONE & JOINT CENTER LC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-05
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3298742401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057392Medicare PIN