MEDICARE: UTAH NEUROREHABILITATION, 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	208100000X	Physical Medicine & Rehabilitation Physician	1754861205	UT

General Provider Information

NPI Number	:	1548536725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UTAH NEUROREHABILITATION, INC

Provider Business Mailing Address
First Line	:	4398 ADONIS DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3433
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4398 ADONIS DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3433
Country	:	US
Telephone Number	:	801-750-6933
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JUDIGH GOOCH
Credential	:	MD
Telephone Number	:	801-750-6933

Provider Enumeration Date	:	04/01/2012
Last Update Date	:	04/01/2012

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