Provider Demographics
NPI:1497320691
Name:ROGUE REHABILITATION AND PERFORMANCE
Entity Type:Organization
Organization Name:ROGUE REHABILITATION AND PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHILTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:503-975-5149
Mailing Address - Street 1:1547 W DUPONT AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1470 400 WEST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115
Practice Address - Country:US
Practice Address - Phone:503-975-5149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1528477635Medicaid