Healthcare Provider Details

I. General information

NPI: 1487226817
Provider Name (Legal Business Name): JUAN TORRES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 S 500 W
SALT LAKE CITY UT
84115-5149
US

IV. Provider business mailing address

1078 S 1400 W
SALT LAKE CITY UT
84104-3233
US

V. Phone/Fax

Practice location:
  • Phone: 805-478-2911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number10552923-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: