MEDICARE: ROLAYNE G MATTSSON RPT

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	105723-2401	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	47628	OTHER	UT	PEHP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	107008276102	OTHER	UT	IHC-SELECTHEALTH
4	297982	OTHER	UT	DMBA

General Provider Information

NPI Number	:	1831246271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROLAYNE G MATTSSON RPT

Provider Business Mailing Address
First Line	:	380 E 1500 S
Second Line	:
City	:	HEBER CITY
State	:	UT
Zip	:	84032-3940
Country	:	US
Telephone Number	:	435-654-5607
Fax Number	:	435-654-2602

Provider Business Practice Location Address
First Line	:	380 E 1500 S
Second Line	:
City	:	HEBER CITY
State	:	UT
Zip	:	84032-3940
Country	:	US
Telephone Number	:	435-654-5607
Fax Number	:	435-654-2602

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

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	07/09/2007

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Directions to “ ROLAYNE G MATTSSON RPT” Practice Location

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