Healthcare Provider Details

I. General information

NPI: 1669228060
Provider Name (Legal Business Name): BRIAN KINLACHEENY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S CHIPETA WAY
SALT LAKE CITY UT
84108-1222
US

IV. Provider business mailing address

4558 W RUPLE RIDGE LN
HERRIMAN UT
84096-2949
US

V. Phone/Fax

Practice location:
  • Phone: 801-583-2500
  • Fax:
Mailing address:
  • Phone: 801-628-9625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: