Healthcare Provider Details

I. General information

NPI: 1275154767
Provider Name (Legal Business Name): AUSTIN BUD HOLDER COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 COTTONWOOD ST
MURRAY UT
84107
US

IV. Provider business mailing address

5273 S CARPENTER CV
TAYLORSVILLE UT
84129-1564
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-7000
  • Fax:
Mailing address:
  • Phone: 801-884-8755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number9459049-4202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: