Healthcare Provider Details

I. General information

NPI: 1265885222
Provider Name (Legal Business Name): JARED SWEIGARD LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E 6TH AVE
SALT LAKE CITY UT
84103-2729
US

IV. Provider business mailing address

333 E 6TH AVE
SALT LAKE CITY UT
84103-2729
US

V. Phone/Fax

Practice location:
  • Phone: 440-223-2708
  • Fax:
Mailing address:
  • Phone: 440-223-2708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number9829778-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: