Healthcare Provider Details

I. General information

NPI: 1164971925
Provider Name (Legal Business Name): UTAH STATE UNIVERSIRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7425 OLD MAIN HL
LOGAN UT
84322-2400
US

IV. Provider business mailing address

7425 OLD MAIN HILL
LOGAN UT
84322-2400
US

V. Phone/Fax

Practice location:
  • Phone: 435-797-3444
  • Fax:
Mailing address:
  • Phone: 435-797-3444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL WILLIAMS
Title or Position: ASSOCIATE AD FOR ATHLETIC TRAINING
Credential: M.S., ATC
Phone: 435-797-3444