=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861599227
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH PAUL COLLEDGE PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2120 N 400 E
-----------------------------------------------------
City | NORTH OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84414-7238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-668-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3578 N. 875 E.
-----------------------------------------------------
City | NORTH OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-668-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 103041-2401
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------