Healthcare Provider Details

I. General information

NPI: 1649646548
Provider Name (Legal Business Name): ERICK ZOTELO-AVILA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 W 7800 S
WEST JORDAN UT
84088-4025
US

IV. Provider business mailing address

4444 S 700 E
MURRAY UT
84107-3075
US

V. Phone/Fax

Practice location:
  • Phone: 801-748-1229
  • Fax:
Mailing address:
  • Phone: 801-268-4887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: