MEDICARE: PEAK PERFORMANCE PHYSICAL THERAPY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	5080663-2401	UT

General Provider Information

NPI Number	:	1073933966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEAK PERFORMANCE PHYSICAL THERAPY, PC

Provider Business Mailing Address
First Line	:	515 ASPEN DRIVE
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098
Country	:	US
Telephone Number	:	801-718-5378
Fax Number	:

Provider Business Practice Location Address
First Line	:	2760 RASMUSSEN RD
Second Line	:	D2-D3
City	:	PARK CITY
State	:	UT
Zip	:	84098-5684
Country	:	US
Telephone Number	:	801-718-5378
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JESSICA JACOBSEN TIDSWELL
Credential	:	PT, DPT, SCS, ATC
Telephone Number	:	801-718-5378

Provider Enumeration Date	:	04/18/2014
Last Update Date	:	05/01/2014

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