Provider Demographics
NPI:1972915874
Name:SUMMIT SPORTS PERFORMANCE AND REHAB CENTER, PLLC
Entity Type:Organization
Organization Name:SUMMIT SPORTS PERFORMANCE AND REHAB CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:TIDSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, SCS, ATC
Authorized Official - Phone:801-718-5378
Mailing Address - Street 1:2760 RASMUSSEN RD
Mailing Address - Street 2:SUITES D2-D3
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5684
Mailing Address - Country:US
Mailing Address - Phone:801-718-5378
Mailing Address - Fax:
Practice Address - Street 1:2760 RASMUSSEN RD
Practice Address - Street 2:SUITES D2-D3
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5684
Practice Address - Country:US
Practice Address - Phone:801-718-5378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5080663-2401261QP2000X
UT5080663-4810261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy