Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 96317081-1202 | UT |
NPI | 1447381223 |
---|---|
Provider Name | Corey Joe Sondrup |
First Address | Ogden, UT 84403-2559 |
Second Address | Ogden, UT 84403-2559 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U62190 | (02) | UT |