MEDICARE: MEDICOR, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053318709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICOR, LLC

Provider Business Mailing Address
First Line	:	3652 BRIGHTON POINT DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-5555
Country	:	US
Telephone Number	:	801-942-5543
Fax Number	:	801-944-4877

Provider Business Practice Location Address
First Line	:	2469 FORT UNION BLVD
Second Line	:	STE 105
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3343
Country	:	US
Telephone Number	:	801-942-5543
Fax Number	:	801-944-4877

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RICHARD E FROST
Credential	:
Telephone Number	:	801-942-5543

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	02/22/2012

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