Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 363699-1202 | UT |
NPI | 1124278817 |
---|---|
Provider Name | Dr. Bradley Glen Crump |
First Address | St George, UT 84790-2535 |
Second Address | Ivins, UT 84738-6178 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/09/2008 |
Last Update Date | 30/09/2008 |