Provider Demographics
NPI:1427020312
Name:SPENCER, RICHARD JAY (ATC-L)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JAY
Last Name:SPENCER
Suffix:
Gender:M
Credentials:ATC-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2599 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1373
Mailing Address - Country:US
Mailing Address - Phone:801-466-4914
Mailing Address - Fax:
Practice Address - Street 1:2166 S 1700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-4123
Practice Address - Country:US
Practice Address - Phone:801-484-4343
Practice Address - Fax:801-481-4893
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6321066-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer