MEDICARE: BRAIN INJURY ASSOCIATION OF UTAH

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	251V00000X	Voluntary or Charitable Agency	N10744	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

General Provider Information

NPI Number	:	1326105198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAIN INJURY ASSOCIATION OF UTAH

Provider Business Mailing Address
First Line	:	1800 S WEST TEMPLE
Second Line	:	SUITE 203
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-1851
Country	:	US
Telephone Number	:	801-484-2240
Fax Number	:	801-484-5932

Provider Business Practice Location Address
First Line	:	1800 S WEST TEMPLE
Second Line	:	SUITE 203
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-1851
Country	:	US
Telephone Number	:	801-484-2240
Fax Number	:	801-484-5932

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	RON S. ROSKOS
Credential	:
Telephone Number	:	801-484-2240

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	08/22/2020

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