Healthcare Provider Details

I. General information

NPI: 1730924580
Provider Name (Legal Business Name): SUNDARA MHS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2024
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

7533 S CENTER VIEW CT STE N
WEST JORDAN UT
84084-5526
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 Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TAMARA BROADHEAD
Title or Position: MEDICAL DIRECTOR
Credential: DNP
Phone: 817-319-9475