MEDICARE: STEPHANIE BRISCOE ST

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	171W00000X	Contractor	7496877-4102	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	27-0926842	OTHER	UT	MEDICARE TAX #

General Provider Information

NPI Number	:	1427359199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE BRISCOE ST

Provider Business Mailing Address
First Line	:	1018 ATHERTON DR
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84123-3470
Country	:	US
Telephone Number	:	801-716-2289
Fax Number	:

Provider Business Practice Location Address
First Line	:	3257 E 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2246
Country	:	US
Telephone Number	:	801-716-2289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2010
Last Update Date	:	07/10/2015

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Directions to “ STEPHANIE BRISCOE ST” Practice Location

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