Provider Demographics
NPI:1336413798
Name:PACK PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PACK PHYSICAL THERAPY, INC.
Other - Org Name:IMPACKT PHYSICAL THERAPY AND SPORTS RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRODIE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:801-260-3100
Mailing Address - Street 1:11531 S DISTRICT DR STE 1200
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5782
Mailing Address - Country:US
Mailing Address - Phone:801-260-3100
Mailing Address - Fax:
Practice Address - Street 1:11531 S DISTRICT DR STE 1200
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5782
Practice Address - Country:US
Practice Address - Phone:949-350-6370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28869225100000X, 2251H1200X, 2251S0007X, 2251X0800X
225100000X, 2251S0007X, 2251X0800X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2774652-2401OtherUTAH DEPARTMENT OF COMMERCE DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING
UT2774652-2401OtherUTAH DEPARTMENT OF COMMERCE DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING