Healthcare Provider Details

I. General information

NPI: 1043762479
Provider Name (Legal Business Name): PREMIER FAMILY MEDICAL - EAGLE MOUNTAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3943 E PONY EXPRESS PKWY STE 120
EAGLE MOUNTAIN UT
84005-5543
US

IV. Provider business mailing address

3943 E PONY EXPRESS PKWY STE 120
EAGLE MOUNTAIN UT
84005-5543
US

V. Phone/Fax

Practice location:
  • Phone: 801-756-3511
  • Fax: 801-756-1705
Mailing address:
  • Phone: 801-789-5566
  • Fax: 801-642-2941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER GUYMON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 801-769-2571