Healthcare Provider Details

I. General information

NPI: 1720054794
Provider Name (Legal Business Name): TOM T. IRIYE A.T.,C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 E SOUTH CAMPUS DR
SALT LAKE CITY UT
84112-0900
US

IV. Provider business mailing address

10744 S 1120 E
SANDY UT
84094-5091
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-7044
  • Fax: 801-581-8290
Mailing address:
  • Phone: 801-585-7044
  • Fax: 801-581-8290

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: