MEDICARE: MRS. MARJORIE GALVIN BOOTH 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	6016284-2401	UT

General Provider Information

NPI Number	:	1811143456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARJORIE GALVIN BOOTH PT

Provider Business Mailing Address
First Line	:	6531 LANDMARK DR
Second Line	:	STE E
City	:	PARK CITY
State	:	UT
Zip	:	84098-5951
Country	:	US
Telephone Number	:	435-649-7335
Fax Number	:	435-649-7568

Provider Business Practice Location Address
First Line	:	6531 LANDMARK DR
Second Line	:	STE E
City	:	PARK CITY
State	:	UT
Zip	:	84098-5951
Country	:	US
Telephone Number	:	435-649-7335
Fax Number	:	435-649-7568

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

Provider Enumeration Date	:	08/14/2008
Last Update Date	:	08/14/2008

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