Provider Demographics
NPI:1518480870
Name:MUNCEY, KEVIN R (PT, DPT, ATC, SCS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:MUNCEY
Suffix:
Gender:M
Credentials:PT, DPT, ATC, SCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 E 340 N
Mailing Address - Street 2:
Mailing Address - City:VINEYARD
Mailing Address - State:UT
Mailing Address - Zip Code:84059-7504
Mailing Address - Country:US
Mailing Address - Phone:208-691-7738
Mailing Address - Fax:
Practice Address - Street 1:564 W 700 S STE 203
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3785
Practice Address - Country:US
Practice Address - Phone:208-691-7738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9876846-2401225100000X
UT9876846-8016225100000X
UT9876846-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500764000Medicaid