Healthcare Provider Details

I. General information

NPI: 1265073761
Provider Name (Legal Business Name): TYSON B ROCKWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2019
Last Update Date: 10/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S 500 E
SALT LAKE CITY UT
84102-2753
US

IV. Provider business mailing address

370 CULROSS CIR
STANSBURY PARK UT
84074-8166
US

V. Phone/Fax

Practice location:
  • Phone: 801-328-6033
  • Fax: 435-328-6027
Mailing address:
  • Phone: 435-840-2767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number7338418-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: