MEDICARE: INTERVENTIONAL MEDICAL CENTER

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	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1558871590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVENTIONAL MEDICAL CENTER

Provider Business Mailing Address
First Line	:	32 W WINCHESTER ST STE 100
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-5609
Country	:	US
Telephone Number	:	801-998-8256
Fax Number	:	801-849-0340

Provider Business Practice Location Address
First Line	:	1972 W 5400 S
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84129-1459
Country	:	US
Telephone Number	:	801-998-8256
Fax Number	:	801-849-0340

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. JENNIE N NGUYEN
Credential	:
Telephone Number	:	801-679-3488

Provider Enumeration Date	:	10/04/2017
Last Update Date	:	10/24/2017

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Directions to “INTERVENTIONAL MEDICAL CENTER ” Practice Location

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