Healthcare Provider Details

I. General information

NPI: 1538188479
Provider Name (Legal Business Name): NORDELL E PETERSON P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/09/2007
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 SOUTH 1500 EAST
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 Number1101962401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: