MEDICARE: MR. KENNETH PAUL COLLEDGE 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	103041-2401	UT

General Provider Information

NPI Number	:	1861599227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH PAUL COLLEDGE PT

Provider Business Mailing Address
First Line	:	3578 N. 875 E.
Second Line	:
City	:	NORTH OGDEN
State	:	UT
Zip	:	84414
Country	:	US
Telephone Number	:	801-668-3500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2120 N 400 E
Second Line	:
City	:	NORTH OGDEN
State	:	UT
Zip	:	84414-7238
Country	:	US
Telephone Number	:	801-668-3500
Fax Number	:

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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