Individual
TYLER STEVEN POULSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
21260 NORTH 1450 EAST, MORONI, UT 84646
(435) 445-5200
(435) 445-5201
Mailing address
PO BOX 461, MORONI, UT 84646-0461
(435) 445-5200
(435) 445-5201
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
272503815
—
UT
Enumeration date
04/18/2012
Last updated
04/18/2012
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