Healthcare Provider Details

I. General information

NPI: 1053015552
Provider Name (Legal Business Name): GREGORY JOSEPH HEUER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2166 S 1700 E
SALT LAKE CITY UT
84106-4123
US

IV. Provider business mailing address

2166 S 1700 E
SALT LAKE CITY UT
84106-4123
US

V. Phone/Fax

Practice location:
  • Phone: 801-484-4343
  • Fax:
Mailing address:
  • Phone: 435-484-4343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number8858452-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: