Healthcare Provider Details

I. General information

NPI: 1164888129
Provider Name (Legal Business Name): ELIZABETH BIRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11075 S STATE ST STE 33
SANDY UT
84070-5183
US

IV. Provider business mailing address

PO BOX 330
MAGNA UT
84044-0330
US

V. Phone/Fax

Practice location:
  • Phone: 801-990-4300
  • Fax: 801-967-2127
Mailing address:
  • Phone: 801-990-4300
  • Fax: 801-967-2127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT5970
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: