Healthcare Provider Details

I. General information

NPI: 1437671583
Provider Name (Legal Business Name): KG MEDICAL CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 E 200 N
AMERICAN FORK UT
84003-1742
US

IV. Provider business mailing address

2040 E MURRAY HOLLADAY RD STE 115
SLC UT
84117-5139
US

V. Phone/Fax

Practice location:
  • Phone: 801-319-2772
  • Fax:
Mailing address:
  • Phone: 801-430-0282
  • Fax: 801-508-2273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number7382930-0160
License Number StateUT

VIII. Authorized Official

Name: MR. GREGORY Q. JACKSON
Title or Position: OWNER
Credential:
Phone: 801-430-0282