Provider Demographics
NPI:1376678334
Name:CHURCH, KEVIN DEE (PT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DEE
Last Name:CHURCH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5255 S 4015 W
Mailing Address - Street 2:SUITE 205
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84118-4257
Mailing Address - Country:US
Mailing Address - Phone:801-957-1797
Mailing Address - Fax:801-957-1941
Practice Address - Street 1:5255 S 4015 W
Practice Address - Street 2:SUITE 205
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-4257
Practice Address - Country:US
Practice Address - Phone:801-957-1797
Practice Address - Fax:801-957-1941
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT119835-2401225100000X
AZ5665225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP09797Medicare UPIN