Provider Demographics
NPI:1336844711
Name:ROBERTS, CHAZ
Entity type:Individual
Prefix:
First Name:CHAZ
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 E 3745 S APT 6
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1992
Mailing Address - Country:US
Mailing Address - Phone:385-249-7390
Mailing Address - Fax:
Practice Address - Street 1:177 W PRICE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-4345
Practice Address - Country:US
Practice Address - Phone:385-249-7390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT175T00000X175T00000X
UT175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist