Provider Demographics
NPI:1356458467
Name:MOUNTAIN LAND SPORTS & ORTHOPEDIC PHYSICAL THERAPY OF SANTAQUIN LC
Entity Type:Organization
Organization Name:MOUNTAIN LAND SPORTS & ORTHOPEDIC PHYSICAL THERAPY OF SANTAQUIN LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-942-3311
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1185
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:94 W MAIN ST
Practice Address - Street 2:STE 1
Practice Address - City:SANTAQUIN
Practice Address - State:UT
Practice Address - Zip Code:84655-7064
Practice Address - Country:US
Practice Address - Phone:801-754-5700
Practice Address - Fax:801-942-5955
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN LAND REHABILITATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-24
Last Update Date:2008-07-03
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
466502Medicare ID - Type Unspecified