Healthcare Provider Details

I. General information

NPI: 1508121062
Provider Name (Legal Business Name): RON SQUIRE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 FOOTHILL BLVD
ROCK SPRINGS WY
82901-5610
US

IV. Provider business mailing address

553 E CENTER ST
SPRINGVILLE UT
84663-1550
US

V. Phone/Fax

Practice location:
  • Phone: 307-352-6677
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number82655223501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: