Provider Demographics
NPI:1730194507
Name:WASATCH PHYSICAL THERAPY & SPORTS MEDICINE AT PARK CITY
Entity type:Organization
Organization Name:WASATCH PHYSICAL THERAPY & SPORTS MEDICINE AT PARK CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:IVIE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:435-649-7335
Mailing Address - Street 1:PO BOX 982287
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-2287
Mailing Address - Country:US
Mailing Address - Phone:435-649-7335
Mailing Address - Fax:435-649-7568
Practice Address - Street 1:597 PARKWAY DR
Practice Address - Street 2:SUITE C
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5731
Practice Address - Country:US
Practice Address - Phone:435-649-7335
Practice Address - Fax:435-649-7568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057095OtherMEDICARE PTAN