Provider Demographics
NPI:1699009696
Name:WESTERN SUMMIT REHABILITATION LLC
Entity Type:Organization
Organization Name:WESTERN SUMMIT REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-673-2910
Mailing Address - Street 1:2155 E PANORAMA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2816
Mailing Address - Country:US
Mailing Address - Phone:801-716-2289
Mailing Address - Fax:801-716-2290
Practice Address - Street 1:2155 E PANORAMA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2816
Practice Address - Country:US
Practice Address - Phone:801-716-2289
Practice Address - Fax:801-716-2290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT225100000X, 235Z00000X
225100000X, 225X00000X
UT2012-HHA-91251332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000068359Medicare PIN
UT000068359Medicare UPIN
UT467314Medicare PIN