Healthcare Provider Details

I. General information

NPI: 1720363898
Provider Name (Legal Business Name): CUSTOM SPECIALTY REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 W 3800 S
HOOPER UT
84315-9803
US

IV. Provider business mailing address

5820 W 3800 S
HOOPER UT
84315-9803
US

V. Phone/Fax

Practice location:
  • Phone: 801-781-0084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: SCOTT CHRISTIAN PAULSEN
Title or Position: OWNER
Credential:
Phone: 801-781-0084