Healthcare Provider Details

I. General information

NPI: 1073182937
Provider Name (Legal Business Name): ROSHELLE MARIE LEILUA HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4063 W 12600 S
RIVERTON UT
84096-7302
US

IV. Provider business mailing address

1468 W HUNTERS VIEW CT
RIVERTON UT
84065-6160
US

V. Phone/Fax

Practice location:
  • Phone: 801-495-4800
  • Fax:
Mailing address:
  • Phone: 801-495-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number7984062-4601
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: