=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952865412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVAIL MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2019
-----------------------------------------------------
Last Update Date | 01/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5742 S 1475 E STE 200
-----------------------------------------------------
City | SOUTH OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-4856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-438-4438
-----------------------------------------------------
Fax | 801-469-4499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 446
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84317-0446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-438-4438
-----------------------------------------------------
Fax | 801-469-4499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | JOSHUA SHEPARD
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 801-438-4388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------