MEDICARE: UTAH SPINAL REHABILITAION, PLLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1417192436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UTAH SPINAL REHABILITAION, PLLC

Provider Business Mailing Address
First Line	:	1225 FORT UNION BLVD
Second Line	:	SUITE 120
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84047-1889
Country	:	US
Telephone Number	:	801-563-1116
Fax Number	:	801-563-1117

Provider Business Practice Location Address
First Line	:	1225 FORT UNION BLVD
Second Line	:	SUITE 120
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84047-1889
Country	:	US
Telephone Number	:	801-563-1116
Fax Number	:	801-563-1117

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KEVIN MCDOUGAL
Credential	:	D.C.
Telephone Number	:	801-563-1116

Provider Enumeration Date	:	12/04/2008
Last Update Date	:	12/04/2008

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