Healthcare Provider Details

I. General information

NPI: 1720825573
Provider Name (Legal Business Name): SUNDARA MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14629 S PORTER ROCKWELL BLVD
BLUFFDALE UT
84065
US

IV. Provider business mailing address

14629 S PORTER ROCKWELL BLVD
BLUFFDALE UT
84065
US

V. Phone/Fax

Practice location:
  • Phone: 801-410-1100
  • Fax: 801-332-9577
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TAMARA BROADHEAD
Title or Position: DNP
Credential: DNP
Phone: 801-410-1100