Healthcare Provider Details

I. General information

NPI: 1902291842
Provider Name (Legal Business Name): DARYL RAY EZIDORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH 344 EAST
SALT LAKE CITY UT
84101
US

IV. Provider business mailing address

5636 S 3650 W
TAYLORSVILLE UT
84129-3661
US

V. Phone/Fax

Practice location:
  • Phone: 801-322-3222
  • Fax:
Mailing address:
  • Phone: 801-755-5415
  • 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 Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: