Healthcare Provider Details

I. General information

NPI: 1225947575
Provider Name (Legal Business Name): BLAYNE BRIDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 W 400 N
OREM UT
84057-1916
US

IV. Provider business mailing address

93 E 425 N
VINEYARD UT
84059-6511
US

V. Phone/Fax

Practice location:
  • Phone: 801-714-3366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14292267-2401
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: