Healthcare Provider Details

I. General information

NPI: 1922300078
Provider Name (Legal Business Name): ARIC LEON KETCHAM P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 COTTONWOOD ST
MURRAY UT
84107-5701
US

IV. Provider business mailing address

3658 S 5725 W
WEST VALLEY CITY UT
84128-2633
US

V. Phone/Fax

Practice location:
  • Phone: 801-570-2000
  • Fax:
Mailing address:
  • Phone: 801-831-4012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: