Provider Demographics
NPI:1154180404
Name:LLAVINA, SAMUEL JONES (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JONES
Last Name:LLAVINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S CHIPETA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1222
Mailing Address - Country:US
Mailing Address - Phone:801-585-0895
Mailing Address - Fax:
Practice Address - Street 1:12222 S 1000 E STE 3
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-3203
Practice Address - Country:US
Practice Address - Phone:801-987-3592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician