Healthcare Provider Details

I. General information

NPI: 1326658246
Provider Name (Legal Business Name): ILAVALU MAPA VAENUKU II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 W 3500 S STE E
WEST VALLEY CITY UT
84119-2668
US

IV. Provider business mailing address

3280 W 3500 S STE E
WEST VALLEY CITY UT
84119-2668
US

V. Phone/Fax

Practice location:
  • Phone: 385-347-5208
  • Fax:
Mailing address:
  • Phone: 385-347-5208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: