Facts
- Status
- A
- Credential
- DC
- Type
- Individual
- Enumeration date
- 2017-11-30
- Last updated
- 2017-11-30
Specialties
Licenses
- License UT
- 10573074-1202
Location
- Practice location
- 1920 W 5200 S STE 1
- City
- ROY UT
- Postal code
- 840673467
- Phone
- 801-390-1979
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.