Provider Demographics
NPI:1134457823
Name:SOUTHERN UTAH PHYSICAL THERAPY & REHABILITATION
Entity Type:Organization
Organization Name:SOUTHERN UTAH PHYSICAL THERAPY & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:BRINKERHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:435-867-8024
Mailing Address - Street 1:990 S BENTLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-1887
Mailing Address - Country:US
Mailing Address - Phone:435-867-8024
Mailing Address - Fax:435-867-8034
Practice Address - Street 1:990 S BENTLEY BLVD
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-1887
Practice Address - Country:US
Practice Address - Phone:435-867-8024
Practice Address - Fax:435-867-8034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
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
UT528193197041Medicaid
000055750Medicare PIN
UT528193197041Medicaid