MEDICARE: COLTON PACK

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1326404179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLTON PACK

Provider Business Mailing Address
First Line	:	243 E 400 S STE 300
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-2858
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	243 E 400 S STE 300
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-2858
Country	:	US
Telephone Number	:	801-647-3920
Fax Number	:	801-931-2607

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

Provider Enumeration Date	:	01/10/2016
Last Update Date	:	01/10/2016

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Directions to “ COLTON PACK ” Practice Location

Language	Start Address	Practice Location

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