Healthcare Provider Details

I. General information

NPI: 1457283541
Provider Name (Legal Business Name): THEODORE GERUN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3784 W VALLEY VIEW DR
CEDAR HILLS UT
84062-8085
US

IV. Provider business mailing address

222 S RIVER BEND CT
LEHI UT
84043-4962
US

V. Phone/Fax

Practice location:
  • Phone: 801-407-9998
  • Fax:
Mailing address:
  • Phone: 801-380-3718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberF26-159998
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: