Healthcare Provider Details

I. General information

NPI: 1730240086
Provider Name (Legal Business Name): RICH ELWOOD HALL ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 500 E SUITE 120
LOGAN UT
84341-2408
US

IV. Provider business mailing address

61 N 1600 W
LEWISTON UT
84320-1648
US

V. Phone/Fax

Practice location:
  • Phone: 435-716-2882
  • Fax:
Mailing address:
  • Phone: 435-716-2884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6289571-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: