Provider Demographics
NPI:1194997437
Name:PERREAULT, ADAM ROBERT (MED, ATC)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:ROBERT
Last Name:PERREAULT
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 680751
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84068-0751
Mailing Address - Country:US
Mailing Address - Phone:435-714-9044
Mailing Address - Fax:435-658-5241
Practice Address - Street 1:1500 KEARNS BLVD
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7226
Practice Address - Country:US
Practice Address - Phone:435-714-9044
Practice Address - Fax:435-658-5241
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001574-12255A2300X
UT7085752-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer