=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548891476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VERONICA FRANCES BAIN LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2020
-----------------------------------------------------
Last Update Date | 01/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 W WEBER HIGH DR
-----------------------------------------------------
City | PLEASANT VIEW
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84414-1455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-476-3700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2683 N 1050 E
-----------------------------------------------------
City | NORTH OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84414-2549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-530-3950
-----------------------------------------------------
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 | 8720359-4810
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------