Healthcare Provider Details

I. General information

NPI: 1902145881
Provider Name (Legal Business Name): GORDON A LAURIE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2013
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 W 400 N
OREM UT
84057-1916
US

IV. Provider business mailing address

527 W 400 N
OREM UT
84057-1916
US

V. Phone/Fax

Practice location:
  • Phone: 801-714-3366
  • Fax: 801-714-3227
Mailing address:
  • Phone: 801-714-3366
  • Fax: 801-714-3227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7389933-2401
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: