Healthcare Provider Details

I. General information

NPI: 1568894707
Provider Name (Legal Business Name): JOSEPH BRENT HAGLOCH PA-C, RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 S COTTONWOOD ST STE 320
MURRAY UT
84107-6768
US

IV. Provider business mailing address

5169 S COTTONWOOD ST STE 320
MURRAY UT
84107-6768
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-2531
  • Fax:
Mailing address:
  • Phone: 801-507-2531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number8733335-4901
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8733335-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: