Healthcare Provider Details

I. General information

NPI: 1699232413
Provider Name (Legal Business Name): TODD IRVING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 S REDWOOD RD
SLC UT
84104-5112
US

IV. Provider business mailing address

435 W BEARCAT DR
SALT LAKE CITY UT
84115-2519
US

V. Phone/Fax

Practice location:
  • Phone: 801-363-9414
  • Fax:
Mailing address:
  • Phone: 801-355-2846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: