Provider Demographics
NPI:1710352778
Name:BRETON, DANVIRG
Entity Type:Individual
Prefix:
First Name:DANVIRG
Middle Name:
Last Name:BRETON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 E 5500 S
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1435 VILLAGE DR
Practice Address - Street 2:DEPT. 2805
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84408-5150
Practice Address - Country:US
Practice Address - Phone:801-626-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10374629-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer