Healthcare Provider Details

I. General information

NPI: 1760706766
Provider Name (Legal Business Name): BRITTANY TUCKER PERDUE A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 N 900 E
PROVO UT
84604-1763
US

IV. Provider business mailing address

387 E 1420 S
OREM UT
84058-8323
US

V. Phone/Fax

Practice location:
  • Phone: 801-422-2602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number7598490-4810
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: