Provider Demographics
NPI:1215398615
Name:REDWOOD INJURY TREATMENT CENTER
Entity Type:Organization
Organization Name:REDWOOD INJURY TREATMENT CENTER
Other - Org Name:REDWOOD PHYSICAL THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICAL THERAPIST/CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:EREKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:801-904-3089
Mailing Address - Street 1:6321 S REDWOOD RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6798
Mailing Address - Country:US
Mailing Address - Phone:801-904-3089
Mailing Address - Fax:801-904-3435
Practice Address - Street 1:6321 S REDWOOD RD
Practice Address - Street 2:SUITE 105
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-6798
Practice Address - Country:US
Practice Address - Phone:801-904-3089
Practice Address - Fax:801-904-3435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7376354-2401261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000076049Medicare UPIN