Healthcare Provider Details

I. General information

NPI: 1427572627
Provider Name (Legal Business Name): MACKENZIE BOOTH ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2017
Last Update Date: 07/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 SFH BRIGHAM YOUNG UNIVERSITY
PROVO UT
84602
US

IV. Provider business mailing address

859 HOLROYD DR
OGDEN UT
84403-4512
US

V. Phone/Fax

Practice location:
  • Phone: 801-866-6082
  • Fax:
Mailing address:
  • Phone: 801-866-6082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number10312376-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: