Healthcare Provider Details

I. General information

NPI: 1649842006
Provider Name (Legal Business Name): ANTHONY JOHN ZAMORA
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

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

V. Phone/Fax

Practice location:
  • Phone: 865-210-2628
  • Fax:
Mailing address:
  • Phone: 865-210-2628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number11799532-4901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: