Provider Demographics
NPI:1720363898
Name:CUSTOM SPECIALTY REHAB
Entity Type:Organization
Organization Name:CUSTOM SPECIALTY REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:PAULSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-781-0084
Mailing Address - Street 1:5820 W 3800 S
Mailing Address - Street 2:
Mailing Address - City:HOOPER
Mailing Address - State:UT
Mailing Address - Zip Code:84315-9803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5820 W 3800 S
Practice Address - Street 2:
Practice Address - City:HOOPER
Practice Address - State:UT
Practice Address - Zip Code:84315-9803
Practice Address - Country:US
Practice Address - Phone:801-781-0084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty