Provider Demographics
NPI:1013028505
Name:KFDD PHYSICAL THERAPY & SPORTS MEDICINE CLINIC
Entity Type:Organization
Organization Name:KFDD PHYSICAL THERAPY & SPORTS MEDICINE CLINIC
Other - Org Name:SPORTS MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATION PRESIDENT, BUSINESS OWN
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:HOLMGREN
Authorized Official - Last Name:DAHLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-621-8835
Mailing Address - Street 1:2261 KIESEL AVE.
Mailing Address - Street 2:SUITE #320
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1969
Mailing Address - Country:US
Mailing Address - Phone:801-621-8835
Mailing Address - Fax:801-528-5357
Practice Address - Street 1:2261 KIESEL AVE.
Practice Address - Street 2:SUITE #320
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1969
Practice Address - Country:US
Practice Address - Phone:801-621-8835
Practice Address - Fax:801-528-5357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT115411-2401225100000X, 2251X0800X
UT114380-2401225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTUT02509Medicare UPIN
UT000006631Medicare ID - Type Unspecified
UT000006755Medicare ID - Type Unspecified