Provider Demographics
NPI:1891283487
Name:RENZO, DANIEL KELLY
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:KELLY
Last Name:RENZO
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 1:4460 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4460 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-263-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-29
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
UT171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant