Healthcare Provider Details

I. General information

NPI: 1902263700
Provider Name (Legal Business Name): JEFFREY ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 W 500 S STE 245
BOUNTIFUL UT
84010-8290
US

IV. Provider business mailing address

PO BOX 1687
BOUNTIFUL UT
84011-1687
US

V. Phone/Fax

Practice location:
  • Phone: 801-663-6015
  • Fax:
Mailing address:
  • Phone: 801-663-6015
  • Fax: 435-602-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number12256626-1714
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: