Healthcare Provider Details

I. General information

NPI: 1700902376
Provider Name (Legal Business Name): MOUNTAIN WEST HEARING AND SPEECH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 E 4500 S STE 110
SALT LAKE CITY UT
84107-3056
US

IV. Provider business mailing address

777 E 4500 S STE 110
SALT LAKE CITY UT
84107-3056
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-6497
  • Fax: 801-268-1376
Mailing address:
  • Phone: 801-268-6497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number104094-4101
License Number StateUT

VIII. Authorized Official

Name: RICHARD S VAN WAGONER
Title or Position: PRESIDENT
Credential: M.S. CCC-A
Phone: 801-268-6497