Healthcare Provider Details

I. General information

NPI: 1265986608
Provider Name (Legal Business Name): KURT DESPAIN R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2016
Last Update Date: 08/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 E 100 S STE 301
SALT LAKE CITY UT
84111-1700
US

IV. Provider business mailing address

344 E 100 S STE 301
SALT LAKE CITY UT
84111-1700
US

V. Phone/Fax

Practice location:
  • Phone: 801-322-4257
  • Fax:
Mailing address:
  • Phone: 801-322-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number5901069-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: