Basic Information
| Provider Information | |||||||||
| NPI: | 1225707599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | DALE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 642 N 130 E | ||||||||
| Address2: | |||||||||
| City: | VINEYARD | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840596565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012288968 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1735 S REDWOOD RD STE 115 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841045107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019734434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2021 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.