Healthcare Provider Details

I. General information

NPI: 1972005791
Provider Name (Legal Business Name): BRIDGE PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6017A FASHION POINT DR
SOUTH OGDEN UT
84403-4851
US

IV. Provider business mailing address

6017A FASHION POINT DR
SOUTH OGDEN UT
84403-4851
US

V. Phone/Fax

Practice location:
  • Phone: 801-317-1618
  • Fax: 801-459-3707
Mailing address:
  • Phone: 801-317-1618
  • Fax: 801-459-3707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SANDY WHITAKER
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-317-1618