Provider Demographics
NPI:1760543870
Name:WENGREN, STEVEN D (CPED)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:D
Last Name:WENGREN
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 E. WILMINGTON AVE.
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1421
Mailing Address - Country:US
Mailing Address - Phone:801-466-2884
Mailing Address - Fax:801-466-2884
Practice Address - Street 1:620 E. WILMINGTON AVE.
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1421
Practice Address - Country:US
Practice Address - Phone:801-466-2884
Practice Address - Fax:801-466-2884
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4681840001Medicare NSC