Healthcare Provider Details

I. General information

NPI: 1891975595
Provider Name (Legal Business Name): PIONEER COMPREHENSIVE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12433 FORT ST
DRAPER UT
84020-9363
US

IV. Provider business mailing address

12433 FORT ST
DRAPER UT
84020-9363
US

V. Phone/Fax

Practice location:
  • Phone: 801-576-1086
  • Fax: 801-576-9796
Mailing address:
  • Phone: 801-576-1086
  • Fax: 801-576-9796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number891818251205
License Number StateUT

VIII. Authorized Official

Name: ROBIN OLSEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-576-1086