Provider Demographics
NPI:1033225578
Name:PACK, ROGER E (PT)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:E
Last Name:PACK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 657
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-0657
Mailing Address - Country:US
Mailing Address - Phone:801-225-6246
Mailing Address - Fax:801-225-1525
Practice Address - Street 1:412 W. 800 N.
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057
Practice Address - Country:US
Practice Address - Phone:801-701-6515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1193062401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist