Healthcare Provider Details

I. General information

NPI: 1114106275
Provider Name (Legal Business Name): JILL L NEILSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 S 500 E
OGDEN UT
84405-6907
US

IV. Provider business mailing address

85 MEDICAL DR # 201
SALT LAKE CITY UT
84112-1100
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-0351
  • Fax:
Mailing address:
  • Phone: 801-581-8578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number276612-4901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: