MEDICARE: LIFESTYLE HEARING OF UTAH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251K00000X	Public Health or Welfare Agency	103915-4101	UT

General Provider Information

NPI Number	:	1205250966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESTYLE HEARING OF UTAH

Provider Business Mailing Address
First Line	:	2964 W 4700 S
Second Line	:	SUITE 116
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84129-2557
Country	:	US
Telephone Number	:	801-417-9696
Fax Number	:	801-417-9697

Provider Business Practice Location Address
First Line	:	2964 W 4700 S
Second Line	:	SUITE 116
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84129-2557
Country	:	US
Telephone Number	:	801-417-9696
Fax Number	:	801-417-9697

Authorized Official
Title or Position	:	CLINICAL AUDIOLOGIST
Name	:	MR. JOHN RALPH PATER
Credential	:	M.A.,AAA
Telephone Number	:	801-417-9696

Provider Enumeration Date	:	02/14/2014
Last Update Date	:	02/14/2014

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