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NPI Code Detail

MEDICARE: TRACEY F RADOVAN PT

MEDICARE: TRACEY F RADOVAN 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
1225100000XPhysical Therapist8244561-2401UT

General Provider Information

NPI Number : 1215289897
Entity Type Code : Individual
Provider Name (Legal Business Name) : TRACEY F RADOVAN PT
Provider Business Mailing Address
First Line : 2266 DOC HOLIDAY DR
Second Line :
City : PARK CITY
State : UT
Zip : 84060-7428
Country : US
Telephone Number : 602-617-3742
Fax Number :
Provider Business Practice Location Address
First Line : 2015 SIDEWINDER DR
Second Line :
City : PARK CITY
State : UT
Zip : 84060-7323
Country : US
Telephone Number : 435-645-9095
Fax Number : 435-645-9092
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/08/2012
Last Update Date : 10/08/2012

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