Provider Demographics
NPI:1487780003
Name:QUACKENBUSH, LOUIS HOWARD II (DPT)
Entity type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:HOWARD
Last Name:QUACKENBUSH
Suffix:II
Gender:M
Credentials:DPT
Other - Prefix:DR
Other - First Name:L
Other - Middle Name:HOWARD
Other - Last Name:QUACKENBUSH
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:95 WHITE SAGE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:DELTA
Mailing Address - State:UT
Mailing Address - Zip Code:84624-5555
Mailing Address - Country:US
Mailing Address - Phone:435-864-2551
Mailing Address - Fax:435-864-3573
Practice Address - Street 1:95 WHITE SAGE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:DELTA
Practice Address - State:UT
Practice Address - Zip Code:84624
Practice Address - Country:US
Practice Address - Phone:435-864-2551
Practice Address - Fax:435-864-3573
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT285712-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870644621OtherEIN#
UT870644621OtherEIN#
UTS96709Medicare UPIN