MEDICARE: MR. BRET J. WARDLE PT, DPT

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	10653905-2401	UT

General Provider Information

NPI Number	:	1366889180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRET J. WARDLE PT, DPT

Provider Business Mailing Address
First Line	:	6900 S 900 E STE 100
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-5820
Country	:	US
Telephone Number	:	801-890-6626
Fax Number	:	801-432-8788

Provider Business Practice Location Address
First Line	:	6900 S 900 E STE 100
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-5820
Country	:	US
Telephone Number	:	801-890-6626
Fax Number	:	801-432-8788

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

Provider Enumeration Date	:	06/03/2013
Last Update Date	:	04/18/2018

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