Healthcare Provider Details

I. General information

NPI: 1447604335
Provider Name (Legal Business Name): JOSEPH MCBETH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 S. GUARDSMAN WAY
SALT LAKE CITY UT
84112
US

IV. Provider business mailing address

580 S. GUARDSMAN WAY
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-209-8967
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: