Healthcare Provider Details

I. General information

NPI: 1851785919
Provider Name (Legal Business Name): INDEPENDENCE PHYSICIAN AND RESOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S 500 W
BOUNTIFUL UT
84010-7210
US

IV. Provider business mailing address

640 S 500 W
BOUNTIFUL UT
84010-7210
US

V. Phone/Fax

Practice location:
  • Phone: 801-298-1100
  • Fax: 801-298-1988
Mailing address:
  • Phone: 801-298-1100
  • Fax: 801-298-1988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL FRASURE
Title or Position: MANAGING PARTNER
Credential:
Phone: 801-698-8927