Healthcare Provider Details

I. General information

NPI: 1083438626
Provider Name (Legal Business Name): MOUNTAIN WEST WOUND CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 N 1300 W STE A
CENTERVILLE UT
84014-1883
US

IV. Provider business mailing address

PO BOX 607
CENTERVILLE UT
84014-0607
US

V. Phone/Fax

Practice location:
  • Phone: 801-815-6500
  • Fax:
Mailing address:
  • Phone: 801-815-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: NATHAN PAYNE
Title or Position: DIRECTOR
Credential: DPM
Phone: 801-815-6500