Healthcare Provider Details

I. General information

NPI: 1730828039
Provider Name (Legal Business Name): SAMANTHA LUANN PETERSON CM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 W 1800 N STE A
CLINTON UT
84015-8503
US

IV. Provider business mailing address

1105 N NAYON DR
LAYTON UT
84040-2875
US

V. Phone/Fax

Practice location:
  • Phone: 801-217-3133
  • Fax: 801-528-5067
Mailing address:
  • Phone: 801-882-0286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13952862-4701
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: