MEDICARE: WILDE HEART PT LLC

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	5647258-2401	UT

General Provider Information

NPI Number	:	1134642911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILDE HEART PT LLC

Provider Business Mailing Address
First Line	:	3333 S 900 E STE 140
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84106-2211
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3333 S 900 E STE 140
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84106-2211
Country	:	US
Telephone Number	:	801-824-5424
Fax Number	:

Authorized Official
Title or Position	:	OWNER, PHYSICAL THERAPIST
Name	:	HEATHER WILDE
Credential	:	PT
Telephone Number	:	801-824-5424

Provider Enumeration Date	:	07/24/2017
Last Update Date	:	03/17/2018

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