Provider Demographics
NPI:1952571358
Name:ADVANCED PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:435-652-4455
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84771-0428
Mailing Address - Country:US
Mailing Address - Phone:435-652-4455
Mailing Address - Fax:435-652-4472
Practice Address - Street 1:1490 E FOREMASTER DR
Practice Address - Street 2:STE 110
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4488
Practice Address - Country:US
Practice Address - Phone:435-652-4455
Practice Address - Fax:435-652-4472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4706030002OtherDMERC
UT=========001Medicaid