Provider Demographics
NPI:1023050374
Name:MCKELL THERAPY GROUP, PC
Entity type:Organization
Organization Name:MCKELL THERAPY GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCKELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:801-224-2177
Mailing Address - Street 1:504 E 770 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-4101
Mailing Address - Country:US
Mailing Address - Phone:801-224-2177
Mailing Address - Fax:801-224-2195
Practice Address - Street 1:504 E 770 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4101
Practice Address - Country:US
Practice Address - Phone:801-224-2177
Practice Address - Fax:801-224-2195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3133172401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT518084116022Medicaid
UT518084116022Medicaid