Provider Demographics
NPI:1649870858
Name:HADLOCK, DEVAN (LMT)
Entity type:Individual
Prefix:
First Name:DEVAN
Middle Name:
Last Name:HADLOCK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3324 S HOLLY DR APT 3
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2691
Mailing Address - Country:US
Mailing Address - Phone:801-834-2217
Mailing Address - Fax:
Practice Address - Street 1:3324 S HOLLY DR APT 3
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84109-2691
Practice Address - Country:US
Practice Address - Phone:801-834-2217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7399945-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist