Provider Demographics
NPI:1326486812
Name:SALLEY, TYSON C (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:C
Last Name:SALLEY
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 E 4600 S STE 150534
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3079
Mailing Address - Country:US
Mailing Address - Phone:406-698-9923
Mailing Address - Fax:
Practice Address - Street 1:1145 E 4600 S STE 150534
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3079
Practice Address - Country:US
Practice Address - Phone:406-698-9923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8695287-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer