Healthcare Provider Details

I. General information

NPI: 1740348556
Provider Name (Legal Business Name): ALTA MEDICAL SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10160 E HIGHWAY 210
ALTA UT
84092-8072
US

IV. Provider business mailing address

PO BOX 8072
ALTA UT
84092-8072
US

V. Phone/Fax

Practice location:
  • Phone: 801-742-2273
  • Fax: 888-549-0494
Mailing address:
  • Phone: 801-742-2273
  • Fax: 888-549-0494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH P LIBRE
Title or Position: PRESIDENT
Credential: MD
Phone: 801-742-2273