Provider Demographics
NPI:1538411293
Name:UTAH OUTPATIENT PULMONARY REHAB, LLC
Entity type:Organization
Organization Name:UTAH OUTPATIENT PULMONARY REHAB, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-706-2964
Mailing Address - Street 1:8785 S JORDAN VALLEY WAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9772
Mailing Address - Country:US
Mailing Address - Phone:801-890-7779
Mailing Address - Fax:801-821-4556
Practice Address - Street 1:8785 S JORDAN VALLEY WAY
Practice Address - Street 2:STE 2
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9772
Practice Address - Country:US
Practice Address - Phone:801-890-7779
Practice Address - Fax:801-821-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2278P1005X, 1041C0700X, 225400000X
UT84318600160261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No2278P1005XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedPulmonary RehabilitationGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT464507Medicare Oscar/Certification