Provider Demographics
NPI:1801079439
Name:TOTAL REHAB, INC.
Entity type:Organization
Organization Name:TOTAL REHAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MONT
Authorized Official - Middle Name:B
Authorized Official - Last Name:DIDERICKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:435-734-7178
Mailing Address - Street 1:551 S 455 E
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-1355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-2074
Practice Address - Country:US
Practice Address - Phone:435-734-7178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty