Healthcare Provider Details

I. General information

NPI: 1386981504
Provider Name (Legal Business Name): BEHLE BURNS ATC, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 07/28/2019
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

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

V. Phone/Fax

Practice location:
  • Phone: 801-587-7109
  • Fax: 801-587-7111
Mailing address:
  • Phone: 801-587-7109
  • Fax: 801-587-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number8021359-4810
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: