Provider Demographics
NPI:1568147148
Name:CARMONA-DEVILLE, JUAN (DPT)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:CARMONA-DEVILLE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9844 S 1300 E STE 300
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-4693
Mailing Address - Country:US
Mailing Address - Phone:801-571-0099
Mailing Address - Fax:
Practice Address - Street 1:5316 S WOODROW ST STE 100
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5331
Practice Address - Country:US
Practice Address - Phone:801-261-9255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13403181-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist