Provider Demographics
NPI:1205250966
Name:LIFESTYLE HEARING OF UTAH
Entity type:Organization
Organization Name:LIFESTYLE HEARING OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL AUDIOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:PATER
Authorized Official - Suffix:
Authorized Official - Credentials:MA,AAA
Authorized Official - Phone:801-417-9696
Mailing Address - Street 1:2964 W 4700 S
Mailing Address - Street 2:SUITE 116
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84129-2557
Mailing Address - Country:US
Mailing Address - Phone:801-417-9696
Mailing Address - Fax:801-417-9697
Practice Address - Street 1:2964 W 4700 S
Practice Address - Street 2:SUITE 116
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84129-2557
Practice Address - Country:US
Practice Address - Phone:801-417-9696
Practice Address - Fax:801-417-9697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT103915-4101251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare