Provider Demographics
NPI:1710590286
Name:SHIPLEY, DALLAS
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:
Last Name:SHIPLEY
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 1:5059 W DUCKHORN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-8144
Mailing Address - Country:US
Mailing Address - Phone:605-471-0089
Mailing Address - Fax:
Practice Address - Street 1:201 PRESIDENTS CIR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-9049
Practice Address - Country:US
Practice Address - Phone:605-471-0089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT9329717-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program