MEDICARE: RETA NICHOLE MANWILL DEM

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	175M00000X	Lay Midwife

General Provider Information

NPI Number	:	1063734341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RETA NICHOLE MANWILL DEM

Provider Business Mailing Address
First Line	:	270 COATSVILLE AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-1927
Country	:	US
Telephone Number	:	801-415-9888
Fax Number	:	801-521-0196

Provider Business Practice Location Address
First Line	:	270 COATSVILLE AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-1927
Country	:	US
Telephone Number	:	801-415-9888
Fax Number	:	801-521-0196

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

Provider Enumeration Date	:	02/26/2010
Last Update Date	:	02/26/2010

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