Provider Demographics
NPI:1609073741
Name:PEAK REHABILITATION AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:PEAK REHABILITATION AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BARTLEY
Authorized Official - Middle Name:BRETT
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT, ATC
Authorized Official - Phone:801-568-0240
Mailing Address - Street 1:6782 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2719
Mailing Address - Country:US
Mailing Address - Phone:801-568-0240
Mailing Address - Fax:801-568-9336
Practice Address - Street 1:6782 S 1300 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-2719
Practice Address - Country:US
Practice Address - Phone:801-568-0240
Practice Address - Fax:801-568-9336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6262252-2401225100000X, 2251X0800X
UT5571167-24012251E1200X, 2251X0800X
UT5132199-24012251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Not Answered2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomicsGroup - Single Specialty
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529596285001Medicaid
UT522371229001Medicaid