Healthcare Provider Details

I. General information

NPI: 1114378288
Provider Name (Legal Business Name): INTERMOUNTAIN HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 W 12600 S
RIVERTON UT
84065-7215
US

IV. Provider business mailing address

3741 W 12600 S
RIVERTON UT
84065-7215
US

V. Phone/Fax

Practice location:
  • Phone: 801-285-3400
  • Fax:
Mailing address:
  • Phone: 801-285-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number9811303-8016
License Number StateUT

VIII. Authorized Official

Name: PAM DIBBLEE
Title or Position: DPT, CLINIC MANAGER
Credential: DPT
Phone: 801-285-3400