MEDICARE: DELTA PHYSICAL THERAPY AND SPORTS

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	225X00000X	Occupational Therapist	5530573-4201	UT
2	225100000X	Physical Therapist	285712-2401	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801834700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELTA PHYSICAL THERAPY AND SPORTS

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

Authorized Official
Title or Position	:	PHYSICAL THERAPIST PRESIDENT
Name	:	DR. L HOWARD QUACKENBUSH II
Credential	:	P.T.
Telephone Number	:	435-864-2551

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	09/12/2013

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Directions to “DELTA PHYSICAL THERAPY AND SPORTS ” Practice Location

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