Healthcare Provider Details

I. General information

NPI: 1306076625
Provider Name (Legal Business Name): FORT DUCHESNE INDIAN HEALTH CENTER RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6822 EAST 1000 SOUTH
FORT DUCHESNE UT
84026
US

IV. Provider business mailing address

6822 EAST 1000 SOUTH
FORT DUCHESNE UT
84026
US

V. Phone/Fax

Practice location:
  • Phone: 435-725-6874
  • Fax: 435-725-6889
Mailing address:
  • Phone: 435-725-6874
  • Fax: 435-725-6889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DELBERT GARY MARTIN
Title or Position: CHIEF PHARMACIST
Credential: RPH
Phone: 435-725-6874