Provider Demographics
NPI:1164619078
Name:PRO PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PRO PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:LAYNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:435-946-3512
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:LAKETOWN
Mailing Address - State:UT
Mailing Address - Zip Code:84038-0152
Mailing Address - Country:US
Mailing Address - Phone:435-946-3512
Mailing Address - Fax:435-946-2311
Practice Address - Street 1:20 ADAVILLE DRIVE
Practice Address - Street 2:SUITE 10
Practice Address - City:DIAMONDVILLE
Practice Address - State:WY
Practice Address - Zip Code:83116
Practice Address - Country:US
Practice Address - Phone:307-877-1000
Practice Address - Fax:307-877-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY20136Medicare PIN