Healthcare Provider Details

I. General information

NPI: 1861824245
Provider Name (Legal Business Name): KEVIN DYSLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

862 S MAIN ST
BRIGHAM CITY UT
84302-3320
US

IV. Provider business mailing address

862 S MAIN ST
BRIGHAM CITY UT
84302-3320
US

V. Phone/Fax

Practice location:
  • Phone: 435-723-1799
  • Fax:
Mailing address:
  • Phone: 435-723-1799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: