Healthcare Provider Details

I. General information

NPI: 1083536239
Provider Name (Legal Business Name): MR. GREGORY LEONARD MALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 W DURFEE ST
GRANTSVILLE UT
84029-9627
US

IV. Provider business mailing address

146 E JACKIE WAY APT 8
MURRAY UT
84107-5861
US

V. Phone/Fax

Practice location:
  • Phone: 385-270-7312
  • Fax:
Mailing address:
  • Phone: 385-270-7312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: