Provider Demographics
NPI:1942552476
Name:PIERCE, EVERT THEODORE
Entity Type:Individual
Prefix:
First Name:EVERT
Middle Name:THEODORE
Last Name:PIERCE
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 1:2885 E CHERRY BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4607
Mailing Address - Country:US
Mailing Address - Phone:801-671-8407
Mailing Address - Fax:
Practice Address - Street 1:2885 E CHERRY BLOSSOM LN
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4607
Practice Address - Country:US
Practice Address - Phone:801-671-8407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor