Healthcare Provider Details

I. General information

NPI: 1326518564
Provider Name (Legal Business Name): IAN MICHAEL MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 S WEST TEMPLE
SALT LAKE CITY UT
84115-5218
US

IV. Provider business mailing address

2345 E CAMPUS DR
SALT LAKE CITY UT
84121-3952
US

V. Phone/Fax

Practice location:
  • Phone: 801-664-2224
  • Fax:
Mailing address:
  • Phone: 801-664-2224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: