MEDICARE: UNIVERSITY OF UTAH REHABILITATION AND WELLNESS PROGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2251G0304X	Geriatric Physical Therapist
2	2251H1200X	Hand Physical Therapist
3	2251S0007X	Sports Physical Therapist
4	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1538267232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY OF UTAH REHABILITATION AND WELLNESS PROGRAM

Provider Business Mailing Address
First Line	:	PO BOX 581002
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84158-1002
Country	:	US
Telephone Number	:	801-213-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 WAKARA WAY
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84108-1213
Country	:	US
Telephone Number	:	801-585-2119
Fax Number	:

Authorized Official
Title or Position	:	DEPT CHAIR
Name	:	DR. CHARLES GRAYBILL
Credential	:	PT
Telephone Number	:	801-587-6470

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	09/07/2011

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