Provider Demographics
NPI:1902413099
Name:SOMMERS, JUSTIN GREGORY
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:GREGORY
Last Name:SOMMERS
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 1:2030 E SUMMER WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-4260
Mailing Address - Country:US
Mailing Address - Phone:385-286-9327
Mailing Address - Fax:
Practice Address - Street 1:2030 E SUMMER WAY
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-4260
Practice Address - Country:US
Practice Address - Phone:385-286-9327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10865414-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty