Healthcare Provider Details

I. General information

NPI: 1922861012
Provider Name (Legal Business Name): ELEVATED THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 LOGANDALE DR
LOGANDALE NV
89021-8902
US

IV. Provider business mailing address

PO BOX 791
LOGANDALE NV
89021-0791
US

V. Phone/Fax

Practice location:
  • Phone: 801-717-6445
  • Fax:
Mailing address:
  • Phone: 801-717-6445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN VINCENT RIDER
Title or Position: OWNER
Credential: PHD, MS, OTR/L
Phone: 801-717-6445