Healthcare Provider Details

I. General information

NPI: 1164418505
Provider Name (Legal Business Name): WASATCH ORTHOTICS & PEDORTHICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 E VINE ST
SALT LAKE CITY UT
84107-6515
US

IV. Provider business mailing address

887 E VINE ST
SALT LAKE CITY UT
84107-6515
US

V. Phone/Fax

Practice location:
  • Phone: 801-293-8777
  • Fax: 801-293-0231
Mailing address:
  • Phone: 801-293-8777
  • Fax: 801-293-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MS. SHERYL S PRICE
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 503-493-8288