Provider Demographics
NPI:1720776966
Name:TOLLEY, VICTOR MANUEL (RN)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:MANUEL
Last Name:TOLLEY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7059 W ADDISON VIEW LN
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-5983
Mailing Address - Country:US
Mailing Address - Phone:801-413-9222
Mailing Address - Fax:
Practice Address - Street 1:10 S 2000 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5880
Practice Address - Country:US
Practice Address - Phone:801-413-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11099798-3102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine