Healthcare Provider Details

I. General information

NPI: 1164623765
Provider Name (Legal Business Name): REGAN JAY ARCHIBALD LAC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 S 500 E STE 103
SALT LAKE CITY UT
84102-1094
US

IV. Provider business mailing address

34 S 500 E STE 103
SALT LAKE CITY UT
84102-1094
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-2011
  • Fax: 801-359-8478
Mailing address:
  • Phone: 801-582-2011
  • Fax: 801-359-8478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number20041684
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: