Healthcare Provider Details

I. General information

NPI: 1194631580
Provider Name (Legal Business Name): BAO HA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1787 E FORT UNION BLVD STE 101
SALT LAKE CITY UT
84121-2868
US

IV. Provider business mailing address

2594 N 850 W
PROVO UT
84604-1271
US

V. Phone/Fax

Practice location:
  • Phone: 801-674-0685
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number13161704-2402
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: