Healthcare Provider Details

I. General information

NPI: 1992516124
Provider Name (Legal Business Name): ERIC KLEIN ASUDC INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 05/31/2025
Certification Date: 05/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 S MAIN ST STE 6
TOOELE UT
84074-2136
US

IV. Provider business mailing address

60 S MAIN ST STE 6
TOOELE UT
84074-2136
US

V. Phone/Fax

Practice location:
  • Phone: 435-255-6150
  • Fax: 435-938-7151
Mailing address:
  • Phone: 435-255-6150
  • Fax: 435-938-7151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14223681-6006
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: