=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053716852
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN-MICHAEL KEONI DELLERMANN DC, CCSP, LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2014
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2650 WASHINGTON BLVD STE 208
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84401-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-200-3654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2275 N 2100 E
-----------------------------------------------------
City | LAYTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84040-8084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-200-3654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 12884926-4810
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 12884926-1202
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------