Provider Demographics
NPI:1508531815
Name:ANGELA K SMITH DPT, LLC
Entity Type:Organization
Organization Name:ANGELA K SMITH DPT, LLC
Other - Org Name:CUSTOM PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:KNOWLES
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:435-229-7567
Mailing Address - Street 1:775 E 2660 N
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-6747
Mailing Address - Country:US
Mailing Address - Phone:435-229-7567
Mailing Address - Fax:
Practice Address - Street 1:135 N MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4587
Practice Address - Country:US
Practice Address - Phone:435-557-0709
Practice Address - Fax:435-213-2483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy