Healthcare Provider Details

I. General information

NPI: 1073587424
Provider Name (Legal Business Name): EVAN MICHAEL GWILLIAM DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7733 GRANT ST
EAGLE MOUNTAIN UT
84005-3862
US

IV. Provider business mailing address

7733 GRANT ST
EAGLE MOUNTAIN UT
84005-3862
US

V. Phone/Fax

Practice location:
  • Phone: 360-904-0205
  • Fax:
Mailing address:
  • Phone: 360-904-0205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7744544-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: