Provider Demographics
NPI:1962162073
Name:RICKENBACKER, GREGORY EDWARD (PT, DPT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:EDWARD
Last Name:RICKENBACKER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1176 E 3745 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2443
Mailing Address - Country:US
Mailing Address - Phone:978-886-7937
Mailing Address - Fax:
Practice Address - Street 1:370 E SOUTH TEMPLE STE 150
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1279
Practice Address - Country:US
Practice Address - Phone:801-521-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12615050-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist