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NPI Code Detail

MEDICARE: KENNETH COSTA

MEDICARE: KENNETH COSTA
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
1225100000XPhysical Therapist6022536-2401UT

General Provider Information

NPI Number : 1649319096
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNETH COSTA
Provider Business Mailing Address
First Line : PO 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 : 1952 FORT UNION BLVD
Second Line : # 100
City : SALT LAKE CITY
State : UT
Zip : 84121-6877
Country : US
Telephone Number : 801-942-3311
Fax Number : 801-942-5955
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/05/2007
Last Update Date : 07/08/2007

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Directions to “ KENNETH COSTA ” Practice Location

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