Healthcare Provider Details

I. General information

NPI: 1508429036
Provider Name (Legal Business Name): ERICANDRE ANJOUNIQUE LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 N 200 E STE 1
AMERICAN FORK UT
84003-1739
US

IV. Provider business mailing address

8043 N RIDGE LOOP E APT J9
EAGLE MOUNTAIN UT
84005-4648
US

V. Phone/Fax

Practice location:
  • Phone: 801-396-8850
  • Fax:
Mailing address:
  • Phone: 435-709-5222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6145683-4701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: