MEDICARE: BRANCHOUT CLINICS PLLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1245937432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRANCHOUT CLINICS PLLC

Provider Business Mailing Address
First Line	:	5620 S WATERBURY WAY STE A200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1180
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5620 S WATERBURY WAY STE A200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1180
Country	:	US
Telephone Number	:	801-455-8822
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	JEREMIAH GOLESH
Credential	:
Telephone Number	:	801-455-2687

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	02/08/2023

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Directions to “BRANCHOUT CLINICS PLLC ” Practice Location

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