Healthcare Provider Details

I. General information

NPI: 1255307161
Provider Name (Legal Business Name): BRIAN A ZETTLER MS, ATC, CSCS, PES
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W SOUTH TEMPLE
SALT LAKE CITY UT
84101-1216
US

IV. Provider business mailing address

7701 S 4950 W
WEST JORDAN UT
84084-5516
US

V. Phone/Fax

Practice location:
  • Phone: 801-325-2528
  • Fax: 801-325-2529
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT2017
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: