MEDICARE: MR. STEPHEN REESE SPENCER PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	106176-2401	UT

General Provider Information

NPI Number	:	1003894379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEPHEN REESE SPENCER PT

Provider Business Mailing Address
First Line	:	P.O. BOX 711185
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84171-1185
Country	:	US
Telephone Number	:	801-942-3311
Fax Number	:	801-942-5955

Provider Business Practice Location Address
First Line	:	5734 S 1475 E
Second Line	:	#300
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84403-4596
Country	:	US
Telephone Number	:	801-475-7628
Fax Number	:	801-475-7639

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	08/13/2010

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