Healthcare Provider Details

I. General information

NPI: 1265824254
Provider Name (Legal Business Name): BLAKE JOHNSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 02/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 S WAKARA WAY
SALT LAKE CITY UT
84108-1200
US

IV. Provider business mailing address

1629 W BLACK GOLD DR
BLUFFDALE UT
84065-2386
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-0757
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6976729-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: