MEDICARE: PHYSIOFIT RX 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1528650538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSIOFIT RX PLLC

Provider Business Mailing Address
First Line	:	2552 E 1700 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2704
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2091 E 1300 S STE 203
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2239
Country	:	US
Telephone Number	:	801-923-8836
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL CAISSE
Credential	:	DPT
Telephone Number	:	858-952-4277

Provider Enumeration Date	:	02/10/2021
Last Update Date	:	02/10/2021

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