Healthcare Provider Details

I. General information

NPI: 1649474982
Provider Name (Legal Business Name): MARK SLAUGH MPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 N 200 W
VERNAL UT
84078-2001
US

IV. Provider business mailing address

75 N 200 W
VERNAL UT
84078-2001
US

V. Phone/Fax

Practice location:
  • Phone: 435-789-6757
  • Fax: 435-789-7892
Mailing address:
  • Phone: 435-789-6757
  • Fax: 435-789-7892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number3420832401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: