Healthcare Provider Details

I. General information

NPI: 1538267232
Provider Name (Legal Business Name): UNIVERSITY OF UTAH REHABILITATION AND WELLNESS PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 WAKARA WAY
SLC UT
84108-1213
US

IV. Provider business mailing address

PO BOX 581002
SLC UT
84158-1002
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-2119
  • Fax:
Mailing address:
  • Phone: 801-213-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. CHARLES GRAYBILL
Title or Position: DEPT CHAIR
Credential: PT
Phone: 801-587-6470