Provider Demographics
NPI:1275726788
Name:DELTA PHYSICAL THERAPY AND SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:DELTA PHYSICAL THERAPY AND SPORTS MEDICINE PC
Other - Org Name:FILLMORE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:QUACKENBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:435-864-2551
Mailing Address - Street 1:95 WHITE SAGE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:UT
Mailing Address - Zip Code:84624-5555
Mailing Address - Country:US
Mailing Address - Phone:435-864-2551
Mailing Address - Fax:435-864-3573
Practice Address - Street 1:770 S HIGHWAY 99
Practice Address - Street 2:SUITE A
Practice Address - City:FILLMORE
Practice Address - State:UT
Practice Address - Zip Code:84631
Practice Address - Country:US
Practice Address - Phone:435-743-6100
Practice Address - Fax:435-743-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty