Provider Demographics
NPI:1538267232
Name:UNIVERSITY OF UTAH REHABILITATION AND WELLNESS PROGRAM
Entity type:Organization
Organization Name:UNIVERSITY OF UTAH REHABILITATION AND WELLNESS PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAYBILL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-587-6470
Mailing Address - Street 1:PO BOX 581002
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84158-1002
Mailing Address - Country:US
Mailing Address - Phone:801-213-3800
Mailing Address - Fax:
Practice Address - Street 1:520 WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84108-1213
Practice Address - Country:US
Practice Address - Phone:801-585-2119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT000055956Medicare ID - Type UnspecifiedUTAH MEDICARE