MEDICARE: MR. CHRISTOPHER LEE FIAGLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1033581723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHRISTOPHER LEE FIAGLE

Provider Business Mailing Address
First Line	:	PO BOX 144575
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84114-4575
Country	:	US
Telephone Number	:	385-468-4707
Fax Number	:	385-468-4740

Provider Business Practice Location Address
First Line	:	2100 S STATE STREET
Second Line	:	S2-300
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84114-4575
Country	:	US
Telephone Number	:	385-468-4707
Fax Number	:	385-468-4740

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2015
Last Update Date	:	05/09/2019

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