Provider Demographics
NPI:1891129821
Name:MOAB PHYSICAL THERAPY AND REHABILITATION LLC
Entity Type:Organization
Organization Name:MOAB PHYSICAL THERAPY AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSCIAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:COWERN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:435-210-1985
Mailing Address - Street 1:131 E 100 S
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2641
Mailing Address - Country:US
Mailing Address - Phone:435-210-1985
Mailing Address - Fax:435-355-0410
Practice Address - Street 1:131 E 100 S
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2641
Practice Address - Country:US
Practice Address - Phone:435-210-1985
Practice Address - Fax:435-355-0410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8212548-2401225100000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNO ADDITIONAL NUMBER TO ENTER