Provider Demographics
NPI:1861484131
Name:IVIE, DAN (PT)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:IVIE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:597 PARKWAY DR. STE C
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098
Mailing Address - Country:US
Mailing Address - Phone:435-649-7335
Mailing Address - Fax:435-649-7568
Practice Address - Street 1:597 PARKWAY DR. STE C
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098
Practice Address - Country:US
Practice Address - Phone:435-649-7335
Practice Address - Fax:435-649-7568
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0313197-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005709501Medicare ID - Type Unspecified
UTP33327Medicare UPIN