Healthcare Provider Details

I. General information

NPI: 1558313338
Provider Name (Legal Business Name): LOUIS ROSSI PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SOUTH MAIN
HURRICANE UT
84737
US

IV. Provider business mailing address

1055 N 500 W
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 435-635-9444
  • Fax: 435-635-8148
Mailing address:
  • Phone: 435-635-9444
  • Fax: 435-635-8148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3471141206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: