Basic Information
Provider Information | |||||||||
NPI: | 1780731992 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEAK PERFORMANCE PHYSICAL THERAPY AND FITNESS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 307 | ||||||||
Address2: |   | ||||||||
City: | BOUNTIFUL | ||||||||
State: | UT | ||||||||
PostalCode: | 840110307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8887006907 | ||||||||
FaxNumber: | 8012946917 | ||||||||
Practice Location | |||||||||
Address1: | 23 SOUTH MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | COALVILLE | ||||||||
State: | UT | ||||||||
PostalCode: | 84017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356543719 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2007 | ||||||||
LastUpdateDate: | 11/14/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WADE | ||||||||
AuthorizedOfficialFirstName: | RODNEY | ||||||||
AuthorizedOfficialMiddleName: | EDWARD | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4356543719 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5327836-2401 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 529791445001 | 05 | UT |   | MEDICAID |