Healthcare Provider Details

I. General information

NPI: 1144024886
Provider Name (Legal Business Name): BRODY ATHERTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2025
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W WASHINGTON ST
EAST PEORIA IL
61611-2416
US

IV. Provider business mailing address

201 W WASHINGTON ST
EAST PEORIA IL
61611-2416
US

V. Phone/Fax

Practice location:
  • Phone: 801-879-5298
  • Fax:
Mailing address:
  • Phone: 801-879-5298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: