Healthcare Provider Details

I. General information

NPI: 1093231219
Provider Name (Legal Business Name): MICHAEL JUDE CAPOBIANCHI JR. PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 S 8400 W STE 210
MAGNA UT
84044-4909
US

IV. Provider business mailing address

1932 S MCCLELLAND ST APT 3
SALT LAKE CITY UT
84105-3444
US

V. Phone/Fax

Practice location:
  • Phone: 801-250-6733
  • Fax:
Mailing address:
  • Phone: 215-622-6653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number10403368-2401
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number10403368-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: