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General NPI Number Information
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NPI Number | 1952522419
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Entity Type | Organization
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Legal Business Name | BODY TUNE PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 04/22/2020
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Provider Practice Location Address
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Address Line | 5856 HARRISON BLVD STE A
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City | SOUTH OGDEN
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State | UT
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Zip | 84403-2117
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Country | US
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Telephone | 801-475-6415
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Fax | 801-475-6417
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Provider Business Mailing Address
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Address Line | 5856 HARRISON BLVD SUITE A
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City | SOUTH OGDEN
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State | UT
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Zip | 84403-4397
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Country | US
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Telephone | 801-475-6415
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Fax | 801-475-6417
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Authorized Official
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Title or Position | CEO
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Name | KORRYN WIESE
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Credential | PT
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Telephone | 801-391-1585
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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 | 1179052401
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License Number State | UT
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