Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 9379311-4201 | UT |
NPI | 1003303694 |
---|---|
Provider Name | Kyle Fairchild |
First Address | Bountiful, UT 84010-8423 |
Second Address | Salt Lake City, UT 84115-2357 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/04/2018 |
Last Update Date | 18/04/2018 |