Provider Demographics
NPI:1366751430
Name:PHYSICAL MEDICINE CLINIC INC
Entity type:Organization
Organization Name:PHYSICAL MEDICINE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:B
Authorized Official - Last Name:EGBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-566-2449
Mailing Address - Street 1:7669 S 1700 W
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-4007
Mailing Address - Country:US
Mailing Address - Phone:801-566-2449
Mailing Address - Fax:801-566-5435
Practice Address - Street 1:7669 S 1700 W
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-4007
Practice Address - Country:US
Practice Address - Phone:801-566-2449
Practice Address - Fax:801-566-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1676421202111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000056082Medicare PIN
UTT78056Medicare UPIN