Provider Demographics
NPI:1265623805
Name:SANPETE VALLEY PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:SANPETE VALLEY PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:435-283-5662
Mailing Address - Street 1:112 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-1104
Mailing Address - Country:US
Mailing Address - Phone:435-283-5662
Mailing Address - Fax:435-283-5666
Practice Address - Street 1:112 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-1104
Practice Address - Country:US
Practice Address - Phone:435-283-5662
Practice Address - Fax:435-283-5666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4931765-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107043750101OtherINTERMOUNTAIN HEALTHCARE
UT93822OtherPUBLIC EMPLOYEES HEALTH P
UT1023166386Medicaid