Basic Information
| Provider Information | |||||||||
| NPI: | 1497484448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | DILLON | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | DPT, PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1949 W THECKSTON RD | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841295429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352326198 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1034 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2022 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12841649-2401 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.