Healthcare Provider Details

I. General information

NPI: 1366751430
Provider Name (Legal Business Name): PHYSICAL MEDICINE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2010
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7669 S 1700 W
WEST JORDAN UT
84084-4007
US

IV. Provider business mailing address

7669 S 1700 W
WEST JORDAN UT
84084-4007
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-2449
  • Fax: 801-566-5435
Mailing address:
  • Phone: 801-566-2449
  • Fax: 801-566-5435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number1676421202
License Number StateUT

VIII. Authorized Official

Name: PATRICK B. EGBERT
Title or Position: OWNER AND CHIROPRACTOR
Credential: D.C.
Phone: 801-566-2449