Healthcare Provider Details

I. General information

NPI: 1427494186
Provider Name (Legal Business Name): KORY POULSEN RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2307 N HILL FIELD RD STE 102
LAYTON UT
84041-6890
US

IV. Provider business mailing address

2307 N HILL FIELD RD STE 102
LAYTON UT
84041-6890
US

V. Phone/Fax

Practice location:
  • Phone: 801-825-0200
  • Fax: 801-266-0421
Mailing address:
  • Phone: 801-825-0200
  • Fax: 801-266-0421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number6209500-5701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: