=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568516789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT PHYSICAL THERAPY & SPORTS MEDICINE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 10/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 228 STATE ROAD 248 STE 248
-----------------------------------------------------
City | KAMAS
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84036-8505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-654-0804
-----------------------------------------------------
Fax | 435-654-3314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 13
-----------------------------------------------------
City | HEBER CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84032-0013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-654-0804
-----------------------------------------------------
Fax | 435-654-3314
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BYRON H. HORNER
-----------------------------------------------------
Credential | M.S.P.T.
-----------------------------------------------------
Telephone | 435-654-0804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4819784-2401
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------