Provider Demographics
NPI:1558686428
Name:LANGE, MARK VINCENT (MPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:VINCENT
Last Name:LANGE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FAIRFAX RD AT VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84103
Mailing Address - Country:US
Mailing Address - Phone:801-536-3616
Mailing Address - Fax:
Practice Address - Street 1:FAIRFAX RD AT VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84103
Practice Address - Country:US
Practice Address - Phone:801-536-3616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5611857-2401OtherUTAH STATE LICENSE