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General NPI Number Information
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NPI Number | 1871578203
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Entity Type | Individual
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Provider Name | BRODIE JAMES PACK MPT
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Gender | Male
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Dates
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Enumeration Date | 12/08/2005
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Last Update Date | 02/07/2023
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Provider Practice Location Address
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Address Line | 11531 S DISTRICT DR STE 1200
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City | SOUTH JORDAN
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State | UT
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Zip | 84095-5782
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Country | US
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Telephone | 801-260-3100
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Fax | 801-260-3101
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Provider Business Mailing Address
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Address Line | 11531 S DISTRICT DR STE 1200
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City | SOUTH JORDAN
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State | UT
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Zip | 84095-5782
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Country | US
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Telephone | 801-260-3100
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Fax | 801-260-3101
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2774652-2401
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number | 2774652-2401
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License Number State | UT
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT28869
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 2774652-2401
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License Number State | UT
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