Provider Demographics
NPI:1720148240
Name:PERFORMANCE WEST PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PERFORMANCE WEST PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-295-3553
Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR
Mailing Address - Street 2:STE 350
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7667
Mailing Address - Country:US
Mailing Address - Phone:801-295-3553
Mailing Address - Fax:801-295-3599
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR
Practice Address - Street 2:STE 350
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7667
Practice Address - Country:US
Practice Address - Phone:801-295-3553
Practice Address - Fax:801-295-3599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT200631198225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty