Healthcare Provider Details

I. General information

NPI: 1245307313
Provider Name (Legal Business Name): HOME FREEDOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3448 S 5100 W
WEST HAVEN UT
84401-9435
US

IV. Provider business mailing address

3448 S 5100 W
WEST HAVEN UT
84401-9435
US

V. Phone/Fax

Practice location:
  • Phone: 801-814-3303
  • Fax:
Mailing address:
  • Phone: 801-814-3303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number225X00000X
License Number StateUT

VIII. Authorized Official

Name: MRS. CHARITY SUE DAVIS
Title or Position: MANAGER
Credential: OTRL
Phone: 801-814-3303