Provider Demographics
NPI:1982708418
Name:PENNOCK, BRIAN H (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:H
Last Name:PENNOCK
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 ADAMS AVE PKWY
Mailing Address - Street 2:2B
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6902
Mailing Address - Country:US
Mailing Address - Phone:801-475-0303
Mailing Address - Fax:801-475-0101
Practice Address - Street 1:5300 ADAMS AVE PKWY
Practice Address - Street 2:2B
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6902
Practice Address - Country:US
Practice Address - Phone:801-475-0303
Practice Address - Fax:801-475-0101
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2852142401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD3220Medicaid