Provider Demographics
NPI:1164418505
Name:WASATCH ORTHOTICS & PEDORTHICS, LLC
Entity Type:Organization
Organization Name:WASATCH ORTHOTICS & PEDORTHICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-493-8288
Mailing Address - Street 1:887 E VINE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6515
Mailing Address - Country:US
Mailing Address - Phone:801-293-8777
Mailing Address - Fax:801-293-0231
Practice Address - Street 1:887 E VINE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-6515
Practice Address - Country:US
Practice Address - Phone:801-293-8777
Practice Address - Fax:801-293-0231
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER ORTHOPEDIC GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-21
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
QM0000036359OtherALTIUS
UT=========000Medicaid
QM0000036359OtherALTIUS
1272190001Medicare ID - Type Unspecified
UT=========01001OtherREGENCE BLUECROSS BLUESHI