Healthcare Provider Details

I. General information

NPI: 1033894266
Provider Name (Legal Business Name): TUCKER GAMBLE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1163 E 1220 N
OREM UT
84097-5433
US

IV. Provider business mailing address

161 ROLLING HILLS DR
CENTERVILLE UT
84014-3104
US

V. Phone/Fax

Practice location:
  • Phone: 801-633-8151
  • Fax:
Mailing address:
  • Phone: 801-633-8151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13398777-2401
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: