Provider Demographics
NPI:1346342110
Name:PECK, SHARIK L (PT)
Entity Type:Individual
Prefix:MR
First Name:SHARIK
Middle Name:L
Last Name:PECK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S 200 W
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:UT
Mailing Address - Zip Code:84333-1267
Mailing Address - Country:US
Mailing Address - Phone:435-258-5601
Mailing Address - Fax:435-258-4545
Practice Address - Street 1:405 S 200 W
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:UT
Practice Address - Zip Code:84333-1267
Practice Address - Country:US
Practice Address - Phone:435-258-5601
Practice Address - Fax:435-258-4545
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT-1264174400000X
UT275801-2401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist