Healthcare Provider Details

I. General information

NPI: 1801168794
Provider Name (Legal Business Name): BOUNTIFUL RIDGE ANESTHESIA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 MEDICAL DR
BOUNTIFUL UT
84010-4908
US

IV. Provider business mailing address

962 MILL SHADOW DR
KAYSVILLE UT
84037-4210
US

V. Phone/Fax

Practice location:
  • Phone: 801-299-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5588901-4406
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. KYLE B TURNER
Title or Position: SOLE MBR
Credential: CRNA
Phone: 801-698-8498