MEDICARE: J MANUEL DE LA TORRE INC

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	1041C0700X	Clinical Social Worker	1315073501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164586061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J MANUEL DE LA TORRE INC

Provider Business Mailing Address
First Line	:	1579 W 6005
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84104-2512
Country	:	US
Telephone Number	:	801-973-0655
Fax Number	:	801-973-0655

Provider Business Practice Location Address
First Line	:	1579 W 6005
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84104-2512
Country	:	US
Telephone Number	:	801-973-0655
Fax Number	:	801-973-0655

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	MR. JESUS MANUEL DE LA TORRE
Credential	:	LCSW
Telephone Number	:	801-973-0655

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	08/22/2020

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