Provider Demographics
NPI:1841350675
Name:STAHLE, ROGER WAYNE (LATC)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:WAYNE
Last Name:STAHLE
Suffix:
Gender:M
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 N 300 W
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1716
Mailing Address - Country:US
Mailing Address - Phone:801-798-4060
Mailing Address - Fax:801-798-4004
Practice Address - Street 1:99 N 300 W
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1716
Practice Address - Country:US
Practice Address - Phone:801-798-4060
Practice Address - Fax:801-798-4004
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6309692-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer