Healthcare Provider Details

I. General information

NPI: 1962522078
Provider Name (Legal Business Name): ALTA THERAPIES LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 E 1450 S
CLEARFIELD UT
84015-1610
US

IV. Provider business mailing address

598 W 900 S STE 240
WOODS CROSS UT
84010-8195
US

V. Phone/Fax

Practice location:
  • Phone: 801-693-2303
  • Fax: 801-693-2391
Mailing address:
  • Phone: 801-693-2301
  • Fax: 801-693-2390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. DUSTIN CRAGUN
Title or Position: GENERAL MANAGER
Credential:
Phone: 801-693-2301