Provider Demographics
NPI:1255441481
Name:CANYON RIM PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:CANYON RIM PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUPE
Authorized Official - Suffix:
Authorized Official - Credentials:PT OCS
Authorized Official - Phone:801-486-7542
Mailing Address - Street 1:2295 FOOTHILL DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-4000
Mailing Address - Country:US
Mailing Address - Phone:801-486-7542
Mailing Address - Fax:
Practice Address - Street 1:2295 FOOTHILL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-4000
Practice Address - Country:US
Practice Address - Phone:801-486-7542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT19921748261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057199Medicare UPIN
UT000057199Medicare PIN