Healthcare Provider Details

I. General information

NPI: 1124877907
Provider Name (Legal Business Name): WESTON GEORGE RALLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/18/2024
Certification Date: 05/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5256 E BLACKSMITH RD
EAGLE MOUNTAIN UT
84005
US

IV. Provider business mailing address

5256 E BLACKSMITH RD
EAGLE MOUNTAIN UT
84005
US

V. Phone/Fax

Practice location:
  • Phone: 801-828-7909
  • Fax:
Mailing address:
  • Phone: 801-828-7909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12110748-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: