Provider Demographics
NPI:1134636269
Name:ELEVATION PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ELEVATION PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:D
Authorized Official - Last Name:EREKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:385-405-2712
Mailing Address - Street 1:985 W RIVERDALE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-5601
Mailing Address - Country:US
Mailing Address - Phone:385-405-2712
Mailing Address - Fax:
Practice Address - Street 1:985 W RIVERDALE RD STE 2
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-5601
Practice Address - Country:US
Practice Address - Phone:385-405-2712
Practice Address - Fax:888-595-6786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7376354-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty