Healthcare Provider Details

I. General information

NPI: 1801834700
Provider Name (Legal Business Name): DELTA PHYSICAL THERAPY AND SPORTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 WHITE SAGE AVE SUITE C
DELTA UT
84624-5555
US

IV. Provider business mailing address

95 WHITE SAGE AVE SUITE C
DELTA UT
84624-5555
US

V. Phone/Fax

Practice location:
  • Phone: 435-864-2551
  • Fax: 435-864-3573
Mailing address:
  • Phone: 435-864-2551
  • Fax: 435-864-3573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number285712-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5530573-4201
License Number StateUT

VIII. Authorized Official

Name: DR. L HOWARD QUACKENBUSH II
Title or Position: PHYSICAL THERAPIST PRESIDENT
Credential: P.T.
Phone: 435-864-2551