Healthcare Provider Details

I. General information

NPI: 1063781813
Provider Name (Legal Business Name): INDEPENDENCE REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2011
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5314 N RIVER RUN DR STE 140
PROVO UT
84604-7706
US

IV. Provider business mailing address

5314 N RIVER RUN DR STE 140
PROVO UT
84604-7706
US

V. Phone/Fax

Practice location:
  • Phone: 801-426-4905
  • Fax: 801-426-4953
Mailing address:
  • Phone: 801-426-4905
  • Fax: 801-426-4953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHAD FULLMER
Title or Position: VICE PRESIDENT
Credential:
Phone: 801-494-0486