Healthcare Provider Details

I. General information

NPI: 1376944942
Provider Name (Legal Business Name): LEGACY DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2014
Last Update Date: 09/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 W 500 S SUITE 210
BOUNTIFUL UT
84010-7218
US

IV. Provider business mailing address

1535 LAKEVIEW DR
BOUNTIFUL UT
84010-1561
US

V. Phone/Fax

Practice location:
  • Phone: 385-312-0650
  • Fax: 385-743-3333
Mailing address:
  • Phone: 435-770-9247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number9017921-1204
License Number StateUT

VIII. Authorized Official

Name: DR. JARED REX HEATON
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 435-770-9247