Provider Demographics
NPI:1417192436
Name:UTAH SPINAL REHABILITAION, PLLC
Entity Type:Organization
Organization Name:UTAH SPINAL REHABILITAION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-563-1116
Mailing Address - Street 1:1225 FORT UNION BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1889
Mailing Address - Country:US
Mailing Address - Phone:801-563-1116
Mailing Address - Fax:801-563-1117
Practice Address - Street 1:1225 FORT UNION BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84047-1889
Practice Address - Country:US
Practice Address - Phone:801-563-1116
Practice Address - Fax:801-563-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center