Healthcare Provider Details

I. General information

NPI: 1083650527
Provider Name (Legal Business Name): COLOR COUNTRY PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 N MAIN ST
CEDAR CITY UT
84720-9113
US

IV. Provider business mailing address

PO BOX 3040
CEDAR CITY UT
84721-3040
US

V. Phone/Fax

Practice location:
  • Phone: 435-865-0218
  • Fax: 435-865-0228
Mailing address:
  • Phone: 435-865-0218
  • Fax: 435-865-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BRIAN BURROWS
Title or Position: CEO
Credential:
Phone: 435-865-0218