Healthcare Provider Details

I. General information

NPI: 1063734341
Provider Name (Legal Business Name): RETA NICHOLE MANWILL DEM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RETA NICHOLE PARTNER-PREECE DEM

II. Dates (important events)

Enumeration Date: 02/26/2010
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 COATSVILLE AVE
SALT LAKE CITY UT
84115-1927
US

IV. Provider business mailing address

270 COATSVILLE AVE
SALT LAKE CITY UT
84115-1927
US

V. Phone/Fax

Practice location:
  • Phone: 801-415-9888
  • Fax: 801-521-0196
Mailing address:
  • Phone: 801-415-9888
  • Fax: 801-521-0196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: