Provider Demographics
NPI:1801834700
Name:DELTA PHYSICAL THERAPY AND SPORTS
Entity Type:Organization
Organization Name:DELTA PHYSICAL THERAPY AND SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:L
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:QUACKENBUSH
Authorized Official - Suffix:II
Authorized Official - Credentials:PT
Authorized Official - Phone:435-864-2551
Mailing Address - Street 1:95 WHITE SAGE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:DELTA
Mailing Address - State:UT
Mailing Address - Zip Code:84624-5555
Mailing Address - Country:US
Mailing Address - Phone:435-864-2551
Mailing Address - Fax:435-864-3573
Practice Address - Street 1:95 WHITE SAGE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:DELTA
Practice Address - State:UT
Practice Address - Zip Code:84624-5555
Practice Address - Country:US
Practice Address - Phone:435-864-2551
Practice Address - Fax:435-864-3573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT285712-2401225100000X
UT5530573-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1669788725Medicaid
UT529299099026Medicaid
UTS96709Medicare UPIN
UTU000072728Medicare PIN
UTU000075336Medicare UPIN
UT529299099026Medicaid
UT000067018Medicare PIN