Healthcare Provider Details

I. General information

NPI: 1245723931
Provider Name (Legal Business Name): CLINTON JAMES BOWSER ATC-L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N 400 W APT 5
SALT LAKE CITY UT
84103-1233
US

IV. Provider business mailing address

255 N 400 W APT 5
SALT LAKE CITY UT
84103-1233
US

V. Phone/Fax

Practice location:
  • Phone: 208-520-6829
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number10118496-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: