Provider Demographics
NPI:1447422019
Name:ASHLEY CREEK PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:ASHLEY CREEK PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KULLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:435-789-0022
Mailing Address - Street 1:595 N VERNAL AVE
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-3701
Mailing Address - Country:US
Mailing Address - Phone:435-789-0022
Mailing Address - Fax:435-789-2955
Practice Address - Street 1:595 NORTH VERNAL AVE
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-4819
Practice Address - Country:US
Practice Address - Phone:435-789-0022
Practice Address - Fax:435-789-2955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT121905-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057872Medicare PIN