Healthcare Provider Details

I. General information

NPI: 1619934478
Provider Name (Legal Business Name): MARTY NELSON HEIM PTA, ATC-L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 S 1900 W
ROY UT
84067-2991
US

IV. Provider business mailing address

1396 MONTEGO PL
HOLLADAY UT
84117-5092
US

V. Phone/Fax

Practice location:
  • Phone: 801-779-9975
  • Fax: 801-779-2330
Mailing address:
  • Phone: 801-440-3228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number5405724-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: