Provider Demographics
NPI:1689909772
Name:PROFORM ATHLETICS, LLC
Entity Type:Organization
Organization Name:PROFORM ATHLETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BEZEMER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:435-901-1139
Mailing Address - Street 1:7461 BROOK HOLLOW LOOP RD
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-8262
Mailing Address - Country:US
Mailing Address - Phone:435-901-1139
Mailing Address - Fax:435-940-9127
Practice Address - Street 1:7600 GLENWILD DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5587
Practice Address - Country:US
Practice Address - Phone:435-901-1139
Practice Address - Fax:435-940-9127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4945243-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty