Healthcare Provider Details

I. General information

NPI: 1033742994
Provider Name (Legal Business Name): MOBILE VIVITROL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13032 SNOW CREST CR
DRAPER UT
84020
US

IV. Provider business mailing address

PO BOX 639
DRAPER UT
84020
US

V. Phone/Fax

Practice location:
  • Phone: 801-898-7778
  • Fax:
Mailing address:
  • Phone: 801-558-6564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK G. RICHARDS
Title or Position: OWNER
Credential:
Phone: 801-898-7778