Healthcare Provider Details

I. General information

NPI: 1154180404
Provider Name (Legal Business Name): SAMUEL JONES LLAVINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12222 S 1000 E STE 3
DRAPER UT
84020-3203
US

IV. Provider business mailing address

501 S CHIPETA WAY
SALT LAKE CITY UT
84108-1222
US

V. Phone/Fax

Practice location:
  • Phone: 801-987-3592
  • Fax:
Mailing address:
  • Phone: 801-585-0895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number14245432-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: