Healthcare Provider Details

I. General information

NPI: 1104119957
Provider Name (Legal Business Name): ORTHOPAEDIC THERAPY AND SPORTS PERFORMANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 S MEDICAL DR STE B
BRIGHAM CITY UT
84302-0739
US

IV. Provider business mailing address

1030 S MEDICAL DR STE B
BRIGHAM CITY UT
84302-0739
US

V. Phone/Fax

Practice location:
  • Phone: 435-538-5111
  • Fax: 435-723-9710
Mailing address:
  • Phone: 435-538-5111
  • Fax: 435-723-9710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: SUSAN M TAYLOR
Title or Position: CREDENTIALING REP
Credential:
Phone: 801-505-0821