Healthcare Provider Details

I. General information

NPI: 1144927542
Provider Name (Legal Business Name): KEITH LIVINGSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21360 N 1450 E
MORONI UT
84646-7629
US

IV. Provider business mailing address

330 W 800 S
MOUNT PLEASANT UT
84647-1929
US

V. Phone/Fax

Practice location:
  • Phone: 435-262-1217
  • Fax:
Mailing address:
  • Phone: 435-262-9901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number32253J00000X
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: