Provider Demographics
NPI:1699759357
Name:LARSON, ROGER L (PT)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:L
Last Name:LARSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 FASHION BLVD
Mailing Address - Street 2:STE.# 200
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5417
Mailing Address - Country:US
Mailing Address - Phone:801-266-7534
Mailing Address - Fax:801-266-7547
Practice Address - Street 1:6040 FASHION BLVD
Practice Address - Street 2:STE.# 200
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5417
Practice Address - Country:US
Practice Address - Phone:801-266-7534
Practice Address - Fax:801-266-7547
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105692-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT64-05616OtherUNITED HEALTHCARE
UT107009228101OtherINTERMOUNTAIN HEALTHCARE