MEDICARE: ASHLEY CREEK PHYSICAL THERAPY, INC

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	121905-2401	UT

General Provider Information

NPI Number	:	1447422019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASHLEY CREEK PHYSICAL THERAPY, INC

Provider Business Mailing Address
First Line	:	595 N VERNAL AVE
Second Line	:
City	:	VERNAL
State	:	UT
Zip	:	84078-3701
Country	:	US
Telephone Number	:	435-789-0022
Fax Number	:	435-789-2955

Provider Business Practice Location Address
First Line	:	595 NORTH VERNAL AVE
Second Line	:
City	:	VERNAL
State	:	UT
Zip	:	84078-4819
Country	:	US
Telephone Number	:	435-789-0022
Fax Number	:	435-789-2955

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	MR. JERRRY D KULLAND
Credential	:	P.T.
Telephone Number	:	435-789-0022

Provider Enumeration Date	:	03/24/2008
Last Update Date	:	06/05/2012

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