Provider Demographics
NPI:1225351570
Name:ADVANCED PHYSICAL THERAPY AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CLYDE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:435-654-0410
Mailing Address - Street 1:P.O. BOX 13
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032
Mailing Address - Country:US
Mailing Address - Phone:385-388-4994
Mailing Address - Fax:435-654-0440
Practice Address - Street 1:999 MURRAY HOLLADAY ROAD
Practice Address - Street 2:#102
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117
Practice Address - Country:US
Practice Address - Phone:385-388-4994
Practice Address - Fax:435-654-3314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-01
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1173432401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty