Provider Demographics
NPI:1801107495
Name:RLC PHYSICAL THERAPY & REHAB, LLC
Entity type:Organization
Organization Name:RLC PHYSICAL THERAPY & REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:435-723-6487
Mailing Address - Street 1:PO BOX 150173
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84415-0173
Mailing Address - Country:US
Mailing Address - Phone:801-479-0601
Mailing Address - Fax:801-479-4768
Practice Address - Street 1:990 MEDICAL DR
Practice Address - Street 2:STE U-4
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-4713
Practice Address - Country:US
Practice Address - Phone:435-723-6487
Practice Address - Fax:435-723-6490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT831143802401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000069903Medicare PIN