MEDICARE: ROGER LYNN COLVIN P.T.

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	114380-2401	UT
2	2251X0800X	Orthopedic Physical Therapist	114380-2401	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740390988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER LYNN COLVIN P.T.

Provider Business Mailing Address
First Line	:	990 MEDICAL DR STE U4
Second Line	:
City	:	BRIGHAM CITY
State	:	UT
Zip	:	84302-4714
Country	:	US
Telephone Number	:	435-723-6487
Fax Number	:	435-723-6490

Provider Business Practice Location Address
First Line	:	990 MEDICAL DR STE U4
Second Line	:
City	:	BRIGHAM CITY
State	:	UT
Zip	:	84302-4714
Country	:	US
Telephone Number	:	435-723-6487
Fax Number	:	435-723-6490

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	03/10/2008

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