MEDICARE: MR. CHAD RAND CRAFTS PT

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	PT60629216	WA
2	225100000X	Physical Therapist	8277303-2401	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01610839	OTHER	WA	RR PTANS WVH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700143831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHAD RAND CRAFTS PT

Provider Business Mailing Address
First Line	:	95 WHITE SAGE AVE
Second Line	:
City	:	DELTA
State	:	UT
Zip	:	84624-5555
Country	:	US
Telephone Number	:	435-864-2551
Fax Number	:	435-864-3573

Provider Business Practice Location Address
First Line	:	95 WHITE SAGE AVE
Second Line	:
City	:	DELTA
State	:	UT
Zip	:	84624-5555
Country	:	US
Telephone Number	:	435-864-2551
Fax Number	:	435-864-3573

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2012
Last Update Date	:	07/08/2019

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