Healthcare Provider's Profile
| Full Name | |
|---|
| Type | Facility |
|---|
| Speciality | Family Medicine |
|---|
| Location | 5126 W Daybreak Pkwy, South Jordan, Utah |
|---|
| Accepts Medicare Assignments | Does not participate in Medicare Program. The facility may not accept medicare assignment. |
|---|
NPI Data:
- NPI Number: 1336304419
- Provider Enumeration Date: 07/28/2008
- Last Update Date: 04/23/2012
Medical Identifiers
Medical identifiers for
such as npi, medicare ID, medicare PIN, medicaid, etc.
| Identifier | Type | State | Issuer |
|---|
| 1336304419 | NPI | - | NPPES |
Medical Taxonomies and Licenses
| Taxonomy | Type | License (State) | Status |
|---|
| 152W00000X | Optometrist | (* (Not Available)) | Secondary |
| 163W00000X | Registered Nurse | (* (Not Available)) | Secondary |
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 207R00000X | Internal Medicine | (* (Not Available)) | Secondary |
| 207V00000X | Obstetrics & Gynecology | (* (Not Available)) | Secondary |
| 208000000X | Pediatrics | (* (Not Available)) | Secondary |
| 208100000X | Physical Medicine & Rehabilitation | (* (Not Available)) | Secondary |
| 213E00000X | Podiatrist | (* (Not Available)) | Secondary |
| 225100000X | Physical Therapist | (* (Not Available)) | Secondary |
| 363A00000X | Physician Assistant | (* (Not Available)) | Secondary |
| 363L00000X | Nurse Practitioner | (* (Not Available)) | Secondary |
| 367A00000X | Advanced Practice Midwife | (* (Not Available)) | Secondary |
Medicare Part D Prescriber Enrollment
Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. is NOT enrolled with medicare and thus cannot prescribe medicare part D drugs to patients with medicare part D benefits.
Mailing Address and Practice Location
| Mailing Address | Practice Location Address |
|---|
Po Box 510708,
Salt Lake City, UT 84151-0708
Ph: (801) 587-6303 |
5126 W Daybreak Pkwy,
South Jordan, UT 84095-5994
Ph: (801) 213-4500 |
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