MEDICARE: PERFORMANCE GOLF & WELLNESS CLINIC

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	225100000X	Physical Therapist	325159-2401	UT

General Provider Information

NPI Number	:	1093731754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE GOLF & WELLNESS CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 307
Second Line	:
City	:	BOUNTIFUL
State	:	UT
Zip	:	84011-0307
Country	:	US
Telephone Number	:	888-700-6907
Fax Number	:	801-294-6917

Provider Business Practice Location Address
First Line	:	1285 GUNN AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3039
Country	:	US
Telephone Number	:	801-746-8997
Fax Number	:	801-746-8996

Authorized Official
Title or Position	:	OWNER
Name	:	MR. HENRY WHITE
Credential	:	M.P.T
Telephone Number	:	801-746-8997

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	08/22/2020

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