Healthcare Provider Details

I. General information

NPI: 1730701483
Provider Name (Legal Business Name): FORWARD REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 PARK AVE # 683745
PARK CITY UT
84060-8100
US

IV. Provider business mailing address

PO BOX 683745
PARK CITY UT
84068-3745
US

V. Phone/Fax

Practice location:
  • Phone: 206-795-4360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: CARLY BROOKS
Title or Position: OWNER
Credential: PT, DPT
Phone: 206-795-4360