Healthcare Provider Details

I. General information

NPI: 1336413798
Provider Name (Legal Business Name): PACK PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11531 S DISTRICT DR STE 900
SOUTH JORDAN UT
84095-5780
US

IV. Provider business mailing address

11531 S DISTRICT DR STE 900
SOUTH JORDAN UT
84095-5780
US

V. Phone/Fax

Practice location:
  • Phone: 949-350-6370
  • Fax:
Mailing address:
  • Phone: 801-260-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. BRODIE JAMES PACK
Title or Position: PRESIDENT/PHYSICAL THERAPIST
Credential: MPT
Phone: 801-260-3100