Provider Demographics
NPI:1669568481
Name:BEAR LAKE PHYSICAL AND SPORTS THERAPY PC
Entity type:Organization
Organization Name:BEAR LAKE PHYSICAL AND SPORTS THERAPY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RUTHANN
Authorized Official - Middle Name:
Authorized Official - Last Name:JARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-946-2777
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84028-0276
Mailing Address - Country:US
Mailing Address - Phone:435-946-2777
Mailing Address - Fax:435-946-9777
Practice Address - Street 1:95 WEST 50 SOUTH
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:UT
Practice Address - Zip Code:84028-0276
Practice Address - Country:US
Practice Address - Phone:435-946-2777
Practice Address - Fax:435-946-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3519742401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529198060001Medicaid
ID1366356Medicare PIN