Healthcare Provider Details

I. General information

NPI: 1649902461
Provider Name (Legal Business Name): CEDAR VALLEY FAMILY & FOOT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 E PONY EXPRESS PKWY STE 140
EAGLE MOUNTAIN UT
84005-5548
US

IV. Provider business mailing address

3435 E PONY EXPRESS PKWY STE 140
EAGLE MOUNTAIN UT
84005-5548
US

V. Phone/Fax

Practice location:
  • Phone: 801-789-2444
  • Fax: 801-789-2045
Mailing address:
  • Phone: 385-388-8003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LYNSEY NIELSEN
Title or Position: CLINICAL ADMINISTRATOR
Credential:
Phone: 385-388-8003