Provider Demographics
NPI:1245611987
Name:MENDENHALL, EZEKIAL CRUZ (DPT)
Entity Type:Individual
Prefix:
First Name:EZEKIAL
Middle Name:CRUZ
Last Name:MENDENHALL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-9621
Mailing Address - Country:US
Mailing Address - Phone:307-885-5811
Mailing Address - Fax:307-885-5997
Practice Address - Street 1:680 E MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2251
Practice Address - Country:US
Practice Address - Phone:801-768-2723
Practice Address - Fax:801-768-2725
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9253802-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist