Provider Demographics
NPI:1407982630
Name:INDEPENDENCE REHAB
Entity Type:Organization
Organization Name:INDEPENDENCE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:B
Authorized Official - Last Name:FULLMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-635-6602
Mailing Address - Street 1:797 E 640 N
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-1647
Mailing Address - Country:US
Mailing Address - Phone:801-426-4905
Mailing Address - Fax:801-426-4953
Practice Address - Street 1:1430 E 4500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4208
Practice Address - Country:US
Practice Address - Phone:801-426-4905
Practice Address - Fax:801-426-4953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2011-12-23
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
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT60040Medicare PIN
WAG8882960Medicare PIN
AZZ140401Medicare PIN