Basic Information
| Provider Information | |||||||||
| NPI: | 1114278397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAACKER | ||||||||
| FirstName: | TIMOTHY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 E BENGAL BLVD | ||||||||
| Address2: | E302 | ||||||||
| City: | COTTONWOOD HEIGHTS | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841217135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627217095 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1138 E WILMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841062819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2012 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8225227-2401 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.