Provider Demographics
NPI:1386802403
Name:POULSON, TODD (MSOTR/L)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:POULSON
Suffix:
Gender:M
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 W 275 S
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5247
Mailing Address - Country:US
Mailing Address - Phone:801-593-8136
Mailing Address - Fax:
Practice Address - Street 1:3430 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1231
Practice Address - Country:US
Practice Address - Phone:801-399-5609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT336746-4201314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility