Healthcare Provider Details

I. General information

NPI: 1851807234
Provider Name (Legal Business Name): GARY DAVID MCKENZIE A.T.,C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 COLLEGE AVE
EPHRAIM UT
84627-1550
US

IV. Provider business mailing address

150 COLLEGE AVE
EPHRAIM UT
84627-1550
US

V. Phone/Fax

Practice location:
  • Phone: 435-283-7022
  • Fax: 435-283-7429
Mailing address:
  • Phone: 435-283-7022
  • Fax: 435-283-7429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number10363049-4810
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: