Healthcare Provider Details

I. General information

NPI: 1225681166
Provider Name (Legal Business Name): MOTIVATIONAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 E MAYOR PLACE DR
AMERICAN FORK UT
84003-8015
US

IV. Provider business mailing address

621 E MAYOR PLACE DR
AMERICAN FORK UT
84003-8015
US

V. Phone/Fax

Practice location:
  • Phone: 801-699-6977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARK HAWTHORNE KEEP
Title or Position: OWNER
Credential: MD
Phone: 801-699-6977