Provider Demographics
NPI:1548942303
Name:BROYLES, EDWARD EUGENE (CPSS)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:EUGENE
Last Name:BROYLES
Suffix:
Gender:M
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2487 S 700 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1722
Mailing Address - Country:US
Mailing Address - Phone:801-554-4477
Mailing Address - Fax:
Practice Address - Street 1:2487 S 700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1722
Practice Address - Country:US
Practice Address - Phone:801-554-4477
Practice Address - Fax:385-229-4233
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1553175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist