MEDICARE: DESERET FAMILY PRACTICE, LTD.

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	111N00000X	Chiropractor	4101	AZ
2	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	006034	AZ
3	207Q00000X	Family Medicine Physician
4	207R00000X	Internal Medicine Physician
5	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1215960638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERET FAMILY PRACTICE, LTD.

Provider Business Mailing Address
First Line	:	1425 S GREENFIELD RD
Second Line	:	101
City	:	MESA
State	:	AZ
Zip	:	85206-5529
Country	:	US
Telephone Number	:	480-981-3000
Fax Number	:	480-654-5761

Provider Business Practice Location Address
First Line	:	1425 S GREENFIELD RD
Second Line	:	101
City	:	MESA
State	:	AZ
Zip	:	85206-5529
Country	:	US
Telephone Number	:	480-981-3000
Fax Number	:	480-654-5761

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT J ALLEN
Credential	:	MD
Telephone Number	:	480-981-3000

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	07/31/2017

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