Provider Demographics
NPI:1437175403
Name:PROREHAB PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PROREHAB PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:N
Authorized Official - Last Name:OHLWILER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:435-613-1500
Mailing Address - Street 1:PO BOX 933
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-0933
Mailing Address - Country:US
Mailing Address - Phone:435-613-1500
Mailing Address - Fax:435-613-1501
Practice Address - Street 1:590 E 100 N
Practice Address - Street 2:SUITE 1
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-2640
Practice Address - Country:US
Practice Address - Phone:435-613-1500
Practice Address - Fax:435-613-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4932238-2401225100000X, 332B00000X
UT352637-2401225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055811Medicare PIN
UT4772930001Medicare NSC
UT000057878Medicare PIN