Healthcare Provider Details

I. General information

NPI: 1174190003
Provider Name (Legal Business Name): HEBER VALLEY DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 E GATEWAY DR STE 103
HEBER CITY UT
84032-4611
US

IV. Provider business mailing address

322 E GATEWAY DR STE 103
HEBER CITY UT
84032-4611
US

V. Phone/Fax

Practice location:
  • Phone: 435-315-3147
  • Fax: 435-355-3737
Mailing address:
  • Phone: 435-315-3147
  • Fax: 435-355-3737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSICA COLLINS
Title or Position: PHYSICIAN OWNER
Credential: DO
Phone: 606-694-2836