Healthcare Provider Details

I. General information

NPI: 1649911975
Provider Name (Legal Business Name): BRANDON JAY HALES LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 N MAIN ST # 3C
CEDAR CITY UT
84721-9746
US

IV. Provider business mailing address

123 S STATE ST
SALINA UT
84654-1346
US

V. Phone/Fax

Practice location:
  • Phone: 435-668-5500
  • Fax:
Mailing address:
  • Phone: 435-633-0617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number11883307-4810
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: