Healthcare Provider Details

I. General information

NPI: 1548825672
Provider Name (Legal Business Name): DANIEL BOLANOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 S GENEVA RD
OREM UT
84058-2217
US

IV. Provider business mailing address

1875 S GENEVA RD
OREM UT
84058-2217
US

V. Phone/Fax

Practice location:
  • Phone: 801-437-0490
  • Fax:
Mailing address:
  • Phone: 801-437-0490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

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: