Provider Demographics
NPI:1871578203
Name:PACK, BRODIE JAMES (MPT)
Entity type:Individual
Prefix:
First Name:BRODIE
Middle Name:JAMES
Last Name:PACK
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:11531 S DISTRICT DR STE 1200
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5782
Mailing Address - Country:US
Mailing Address - Phone:801-260-3100
Mailing Address - Fax:801-260-3101
Practice Address - Street 1:11531 S DISTRICT DR STE 1200
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5782
Practice Address - Country:US
Practice Address - Phone:801-260-3100
Practice Address - Fax:801-260-3101
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2774652-2401225100000X, 2251S0007X, 2251X0800X
CAPT28869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2774652-2401OtherUTAH DEPARTMENT OF COMMERCE DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING
CA28869OtherCALIFORNIA BOARD OF PHYSICAL THERAPY EXAMINERS
CAWPT28869AOtherMC PTAN