Provider Demographics
NPI:1952522419
Name:BODY TUNE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:BODY TUNE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KORRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-391-1585
Mailing Address - Street 1:5856 HARRISON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4397
Mailing Address - Country:US
Mailing Address - Phone:801-475-6415
Mailing Address - Fax:801-475-6417
Practice Address - Street 1:5856 HARRISON BLVD STE A
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2117
Practice Address - Country:US
Practice Address - Phone:801-475-6415
Practice Address - Fax:801-475-6417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1179052401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty