=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053175976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WASATCH RPM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2024
-----------------------------------------------------
Last Update Date | 06/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5825 HARRISON BLVD
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-475-5254
-----------------------------------------------------
Fax | 801-797-0278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5825 HARRISON BLVD
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-475-5254
-----------------------------------------------------
Fax | 801-797-0278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH FYANS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-475-5254
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------