Healthcare Provider Details

I. General information

NPI: 1457964470
Provider Name (Legal Business Name): RYAN TEKOLSTE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

IV. Provider business mailing address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12078806-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0017202
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: