Healthcare Provider Details

I. General information

NPI: 1609085885
Provider Name (Legal Business Name): BEAR LAKE PHYSICAL AND SPORTS THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 SOUTH MAIN
RANDOLPH UT
84064
US

IV. Provider business mailing address

PO BOX 276
GARDEN CITY UT
84028-0276
US

V. Phone/Fax

Practice location:
  • Phone: 435-793-7000
  • Fax: 435-946-9777
Mailing address:
  • Phone: 833-946-2777
  • Fax: 354-363-3146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number351974-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RUTHANN JARMAN
Title or Position: DIRECTOR
Credential:
Phone: 833-946-2777