Provider Demographics
NPI:1629259189
Name:PROFESSIONAL THERAPY AND REHABILITATION LLC
Entity Type:Organization
Organization Name:PROFESSIONAL THERAPY AND REHABILITATION LLC
Other - Org Name:PEAK PHYSICAL THERAPY AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:BUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-798-1626
Mailing Address - Street 1:77 S 400 W
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-2053
Mailing Address - Country:US
Mailing Address - Phone:801-798-1626
Mailing Address - Fax:801-798-1236
Practice Address - Street 1:77 S 400 W
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-2053
Practice Address - Country:US
Practice Address - Phone:801-798-1626
Practice Address - Fax:801-798-1236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2017-08-02
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
UTQM0000076331OtherALTIUS HEALTH PLANS
UTPRA03496OtherMOLINA HEALTHCARE
UT695780OtherDMBA
UTQM0000076331OtherALTIUS HEALTH PLANS
UT=========003Medicaid
UTQM0000076331OtherALTIUS HEALTH PLANS
UT000055270Medicare PIN
UTUT02304Medicare PIN