Healthcare Provider Details

I. General information

NPI: 1346259603
Provider Name (Legal Business Name): MR. KELLY D WARNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 N 400 W
OREM UT
84057-1913
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-224-4080
  • Fax: 801-226-7831
Mailing address:
  • Phone: 801-357-7475
  • Fax: 801-357-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2907312401
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier2907312401
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerUTAH STATE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: