Healthcare Provider Details

I. General information

NPI: 1871578203
Provider Name (Legal Business Name): BRODIE JAMES PACK MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11531 S DISTRICT DR STE 1200
SOUTH JORDAN UT
84095-5782
US

IV. Provider business mailing address

11531 S DISTRICT DR STE 1200
SOUTH JORDAN UT
84095-5782
US

V. Phone/Fax

Practice location:
  • Phone: 801-260-3100
  • Fax: 801-260-3101
Mailing address:
  • Phone: 801-260-3100
  • Fax: 801-260-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2774652-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number2774652-2401
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT28869
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2774652-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: