Provider Demographics
NPI:1629170238
Name:LU, ELAINE T (RPT)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:T
Last Name:LU
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3836
Mailing Address - Country:US
Mailing Address - Phone:801-463-1101
Mailing Address - Fax:801-463-1197
Practice Address - Street 1:3220 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3836
Practice Address - Country:US
Practice Address - Phone:801-463-1101
Practice Address - Fax:801-463-1197
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105876-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870410627Other3
UT000006581Medicare ID - Type Unspecified