Healthcare Provider Details

I. General information

NPI: 1215119870
Provider Name (Legal Business Name): SPORTSMED PHYSICAL THERAPY OF BOUNTIFUL A PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 RENAISSANCE TWN DR STE 420
BOUNTIFUL UT
84010
US

IV. Provider business mailing address

1551 RENAISSANCE TWN DR STE 420
BOUNTIFUL UT
84010-7667
US

V. Phone/Fax

Practice location:
  • Phone: 801-295-8999
  • Fax: 801-292-4168
Mailing address:
  • Phone: 801-295-8999
  • Fax: 801-292-4168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. ROBERT A HAWKES
Title or Position: OWNER
Credential: MSPT
Phone: 801-295-8999