Provider Demographics
NPI:1073588240
Name:RIVERTON PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:RIVERTON PHYSICAL THERAPY, INC.
Other - Org Name:SOUTH MOUNTAIN REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-523-3415
Mailing Address - Street 1:12197 S DRAPER GATE DR STE B
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8078
Mailing Address - Country:US
Mailing Address - Phone:801-523-3415
Mailing Address - Fax:801-523-1843
Practice Address - Street 1:12197 S DRAPER GATE DR STE B
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8078
Practice Address - Country:US
Practice Address - Phone:801-523-3415
Practice Address - Fax:801-523-1843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========016Medicaid
UT000006694Medicare ID - Type UnspecifiedMEDICARE B
UT466515Medicare Oscar/Certification