Healthcare Provider Details

I. General information

NPI: 1053224634
Provider Name (Legal Business Name): ILIA T VAZQUEZ COT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 S MARIO CAPECCHI DR
SALT LAKE CITY UT
84132-0005
US

IV. Provider business mailing address

1911 E CECELIA CIR
HOLLADAY UT
84121-1302
US

V. Phone/Fax

Practice location:
  • Phone: 801-674-9282
  • Fax:
Mailing address:
  • Phone: 801-674-9282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License Number146694
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: