Healthcare Provider Details

I. General information

NPI: 1588836555
Provider Name (Legal Business Name): TERESA INGRAM M.S.;ATC;LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2008
Last Update Date: 03/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 S MAIN ST
GARLAND UT
84312-9797
US

IV. Provider business mailing address

879 W 2880 S
LOGAN UT
84321-6480
US

V. Phone/Fax

Practice location:
  • Phone: 435-257-2500
  • Fax: 435-257-3899
Mailing address:
  • Phone: 435-750-0349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6315811-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: