Healthcare Provider Details

I. General information

NPI: 1710797410
Provider Name (Legal Business Name): BROCK KIRKHAM ELLISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 W 260 N
OREM UT
84057-1970
US

IV. Provider business mailing address

475 W 260 N
OREM UT
84057-1970
US

V. Phone/Fax

Practice location:
  • Phone: 801-221-9930
  • Fax:
Mailing address:
  • Phone:
  • 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:

# 1
Identifier1396085718
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: