Provider Demographics
NPI:1003060906
Name:ROGER L LARSON RPT PC
Entity Type:Organization
Organization Name:ROGER L LARSON RPT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-266-7534
Mailing Address - Street 1:6040 FASHION BLVD
Mailing Address - Street 2:STE. #200
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5417
Mailing Address - Country:US
Mailing Address - Phone:801-266-7534
Mailing Address - Fax:801-266-7547
Practice Address - Street 1:6040 FASHION BLVD
Practice Address - Street 2:STE. #200
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5417
Practice Address - Country:US
Practice Address - Phone:801-266-7534
Practice Address - Fax:801-266-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105692-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000006674Medicare PIN