MEDICARE: KENNETH KELLY FOREMAN PT

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	275391-2401	UT

General Provider Information

NPI Number	:	1215027818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH KELLY FOREMAN PT

Provider Business Mailing Address
First Line	:	PO BOX 581002
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84158-1002
Country	:	US
Telephone Number	:	801-213-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 WAKARA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1213
Country	:	US
Telephone Number	:	801-587-9161
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/08/2007

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