Provider Demographics
NPI:1720623994
Name:HAVILI, ALLAN L
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:L
Last Name:HAVILI
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 1:9045 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3023 N BRONZEWOOD CIR
Practice Address - Street 2:
Practice Address - City:ERDA
Practice Address - State:UT
Practice Address - Zip Code:84074-3302
Practice Address - Country:US
Practice Address - Phone:435-255-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty