Provider Demographics
NPI:1629080544
Name:WASATCH PHYSICAL THERAPY CO
Entity Type:Organization
Organization Name:WASATCH PHYSICAL THERAPY CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:IVIE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:435-649-7335
Mailing Address - Street 1:513 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032
Mailing Address - Country:US
Mailing Address - Phone:435-649-7335
Mailing Address - Fax:435-649-7568
Practice Address - Street 1:513 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032
Practice Address - Country:US
Practice Address - Phone:435-649-7335
Practice Address - Fax:435-649-7568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP33327Medicare UPIN