Provider Demographics
NPI:1609085885
Name:BEAR LAKE PHYSICAL AND SPORTS THERAPY PC
Entity Type:Organization
Organization Name:BEAR LAKE PHYSICAL AND SPORTS THERAPY PC
Other - Org Name:BEAR LAKE PHYSICAL THERAPY - RANDOLPH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTHANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-946-2777
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84028-0276
Mailing Address - Country:US
Mailing Address - Phone:435-946-2777
Mailing Address - Fax:435-946-9777
Practice Address - Street 1:35 SOUTH MAIN
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:UT
Practice Address - Zip Code:84064
Practice Address - Country:US
Practice Address - Phone:435-793-7000
Practice Address - Fax:435-946-9777
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAR LAKE PHYSICAL AND SPORTS THERAPY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT351974-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT816OtherRANDOLPH CITY LICENSE
UT000061386Medicare PIN