Basic Information
| Provider Information | |||||||||
| NPI: | 1538267232 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF UTAH REHABILITATION AND WELLNESS PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 581002 | ||||||||
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| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841581002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012133800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 WAKARA WAY | ||||||||
| Address2: | |||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015852119 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | GRAYBILL | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | DEPT CHAIR | ||||||||
| AuthorizedOfficialTelephone: | 8015876470 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251G0304X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | 2251H1200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | 2251S0007X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.