Healthcare Provider Details

I. General information

NPI: 1538411293
Provider Name (Legal Business Name): UTAH OUTPATIENT PULMONARY REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2012
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8785 S JORDAN VALLEY WAY STE 2
WEST JORDAN UT
84088-9772
US

IV. Provider business mailing address

8785 S JORDAN VALLEY WAY SUITE 2
WEST JORDAN UT
84088-9772
US

V. Phone/Fax

Practice location:
  • Phone: 801-890-7779
  • Fax: 801-821-4556
Mailing address:
  • Phone: 801-890-7779
  • Fax: 801-821-4556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2278P1005X
TaxonomyPulmonary Rehabilitation Certified Respiratory Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number84318600160
License Number StateUT

VIII. Authorized Official

Name: BRETT THOMPSON
Title or Position: ADMINISTRATOR
Credential: P.T.
Phone: 801-706-2964