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General NPI Number Information
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NPI Number | 1104119957
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Entity Type | Organization
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Legal Business Name | ORTHOPAEDIC THERAPY AND SPORTS PERFORMANCE LLC
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Dates
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Enumeration Date | 05/25/2011
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Last Update Date | 01/26/2017
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Provider Practice Location Address
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Address Line | 1030 S MEDICAL DR STE B
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City | BRIGHAM CITY
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State | UT
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Zip | 84302-0739
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Country | US
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Telephone | 435-538-5111
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Fax | 435-723-9710
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Provider Business Mailing Address
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Address Line | 1030 S MEDICAL DR STE B
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City | BRIGHAM CITY
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State | UT
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Zip | 84302-0739
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Country | US
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Telephone | 435-538-5111
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Fax | 435-723-9710
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Authorized Official
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Title or Position | CREDENTIALING REP
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Name | SUSAN M TAYLOR
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Credential |
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Telephone | 801-505-0821
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State | UT
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