Healthcare Provider Details

I. General information

NPI: 1134127202
Provider Name (Legal Business Name): KYLE R ENSLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 S 700 E STE 200
SALT LAKE CITY UT
84106-1466
US

IV. Provider business mailing address

PO BOX 27688
SALT LAKE CITY UT
84127-0688
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-4988
  • Fax: 801-269-9427
Mailing address:
  • Phone: 801-534-1360
  • Fax: 801-366-9883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number167648-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: