Healthcare Provider Details

I. General information

NPI: 1326064874
Provider Name (Legal Business Name): KAYS CREEK PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S 1500 E
CLEARFIELD UT
84015-1621
US

IV. Provider business mailing address

1450 S 1500 E
CLEARFIELD UT
84015-1633
US

V. Phone/Fax

Practice location:
  • Phone: 801-779-0798
  • Fax: 801-779-2798
Mailing address:
  • Phone: 801-397-4340
  • Fax: 801-397-4390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number51508480144
License Number StateUT

VIII. Authorized Official

Name: NORDELL E PETERSON
Title or Position: MANAGER
Credential: P.T.
Phone: 801-397-4340