Provider Demographics
NPI:1851807234
Name:MCKENZIE, GARY DAVID (AT,C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DAVID
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-1550
Mailing Address - Country:US
Mailing Address - Phone:435-283-7022
Mailing Address - Fax:435-283-7429
Practice Address - Street 1:150 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-1550
Practice Address - Country:US
Practice Address - Phone:435-283-7022
Practice Address - Fax:435-283-7429
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10363049-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer