Healthcare Provider Details

I. General information

NPI: 1396137030
Provider Name (Legal Business Name): JOSHUA JUAREZ LAT, ATC, GTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 S 1300 E
SALT LAKE CITY UT
84105-3697
US

IV. Provider business mailing address

1840 S 1300 E
SALT LAKE CITY UT
84105-3697
US

V. Phone/Fax

Practice location:
  • Phone: 801-832-2360
  • Fax:
Mailing address:
  • Phone: 801-832-2367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number9105530-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: