Provider Demographics
NPI:1629005301
Name:MCKELL, JOHN S (MS, PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:MCKELL
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 E 770 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-4101
Mailing Address - Country:US
Mailing Address - Phone:801-224-2177
Mailing Address - Fax:801-224-2195
Practice Address - Street 1:504 E 770 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4101
Practice Address - Country:US
Practice Address - Phone:801-224-2177
Practice Address - Fax:801-224-2195
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3133172401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000067007Medicare ID - Type Unspecified