Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 10312376-4810 | UT |
Y | 213ES0000X | Sports Medicine | 10312376-4810 | UT |
NPI | 1427572627 |
---|---|
Provider Name | Mackenzie Booth |
First Address | Ogden, UT 84403-4512 |
Second Address | Provo, UT 84602 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/07/2017 |
Last Update Date | 29/07/2017 |