Healthcare Provider Details

I. General information

NPI: 1083093702
Provider Name (Legal Business Name): DC CORGIAT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2015
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1916 N 700 W STE 190
LAYTON UT
84041-5726
US

IV. Provider business mailing address

1916 N 700 W STE 190
LAYTON UT
84041-5726
US

V. Phone/Fax

Practice location:
  • Phone: 801-820-6169
  • Fax:
Mailing address:
  • Phone: 801-820-6169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number9133595-6010
License Number StateUT

VIII. Authorized Official

Name: DAMON CORGIAT
Title or Position: SOLE OWNER
Credential:
Phone: 801-808-7435