Provider Demographics
NPI:1568516789
Name:SUMMIT PHYSICAL THERAPY & SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:SUMMIT PHYSICAL THERAPY & SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:H
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:435-654-0804
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-0013
Mailing Address - Country:US
Mailing Address - Phone:435-654-0804
Mailing Address - Fax:435-654-3314
Practice Address - Street 1:228 STATE ROAD 248 STE 248
Practice Address - Street 2:
Practice Address - City:KAMAS
Practice Address - State:UT
Practice Address - Zip Code:84036-8505
Practice Address - Country:US
Practice Address - Phone:435-654-0804
Practice Address - Fax:435-654-3314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4819784-2401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529415583005Medicaid
UT529415583005Medicaid