Provider Demographics
NPI:1730777962
Name:FORTIFY PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:FORTIFY PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:LAYNE
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-431-0211
Mailing Address - Street 1:792 S 3000 E
Mailing Address - Street 2:
Mailing Address - City:ST. GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790
Mailing Address - Country:US
Mailing Address - Phone:208-431-0211
Mailing Address - Fax:
Practice Address - Street 1:792 S 3000 E
Practice Address - Street 2:
Practice Address - City:ST. GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:208-431-0211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ30238OtherPHYSICAL THERAPY LICENSE