Healthcare Provider Details

I. General information

NPI: 1952864423
Provider Name (Legal Business Name): JOEL HANES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 S 300 W STE B
SALT LAKE CITY UT
84115-2399
US

IV. Provider business mailing address

88 W 50 S UNIT J3
CENTERVILLE UT
84014-2294
US

V. Phone/Fax

Practice location:
  • Phone: 801-330-9971
  • Fax:
Mailing address:
  • Phone: 801-330-9971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4945321-4701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: