Provider Demographics
NPI:1962105304
Name:SMITH, KEVIN LEIGH (PT, ATC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEIGH
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 KOLOB ROAD SUNSET CANYON RANCH
Mailing Address - Street 2:
Mailing Address - City:VIRGIN
Mailing Address - State:UT
Mailing Address - Zip Code:84779
Mailing Address - Country:US
Mailing Address - Phone:801-450-4458
Mailing Address - Fax:
Practice Address - Street 1:8243 S OAK CIR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6923
Practice Address - Country:US
Practice Address - Phone:801-210-0127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT326191-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist