Healthcare Provider Details

I. General information

NPI: 1710821566
Provider Name (Legal Business Name): ANGEL GUTIERREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2026
Last Update Date: 04/14/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7625 S 3200 W STE 2
WEST JORDAN UT
84084-2887
US

IV. Provider business mailing address

45 N PARKSIDE ST GLENNS
FERRY ID
83623
US

V. Phone/Fax

Practice location:
  • Phone: 801-915-0359
  • Fax:
Mailing address:
  • Phone: 801-915-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: