Healthcare Provider Details

I. General information

NPI: 1487252003
Provider Name (Legal Business Name): ELAYNA MAY VERGARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S 1350 W BLDG B
OREM UT
84058-3817
US

IV. Provider business mailing address

3844 W JORDAN VIEW DR
LEHI UT
84043-6626
US

V. Phone/Fax

Practice location:
  • Phone: 801-935-4171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: