Healthcare Provider Details

I. General information

NPI: 1215960638
Provider Name (Legal Business Name): DESERET FAMILY PRACTICE, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S GREENFIELD RD 101
MESA AZ
85206-5529
US

IV. Provider business mailing address

1425 S GREENFIELD RD 101
MESA AZ
85206-5529
US

V. Phone/Fax

Practice location:
  • Phone: 480-981-3000
  • Fax: 480-654-5761
Mailing address:
  • Phone: 480-981-3000
  • Fax: 480-654-5761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4101
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number006034
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ROBERT J ALLEN
Title or Position: PRESIDENT
Credential: MD
Phone: 480-981-3000