MEDICARE: NIELS LUND

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	225100000X	Physical Therapist	11393353-2401	UT
2	225100000X	Physical Therapist	PT-1923	WY

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	:	1679119242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIELS LUND

Provider Business Mailing Address
First Line	:	1870 S 1100 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3414
Country	:	US
Telephone Number	:	817-271-3303
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 ARAPAHO ROAD
Second Line	:
City	:	ARAPAHOE
State	:	WY
Zip	:	82510-0014
Country	:	US
Telephone Number	:	307-856-9281
Fax Number	:

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

Provider Enumeration Date	:	11/19/2019
Last Update Date	:	06/01/2020

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Directions to “ NIELS LUND ” Practice Location

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