Healthcare Provider Details

I. General information

NPI: 1528118957
Provider Name (Legal Business Name): BERT EVANS WEAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 ROBINS DR
LAYTON UT
84041-1140
US

IV. Provider business mailing address

451 BRUCE ST APT E
CLEARFIELD UT
84015-2138
US

V. Phone/Fax

Practice location:
  • Phone: 801-779-3001
  • Fax: 801-774-6100
Mailing address:
  • Phone: 801-776-0358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: