Healthcare Provider Details

I. General information

NPI: 1013269406
Provider Name (Legal Business Name): CNM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4749 S HOLLADAY BLVD
HOLLADAY UT
84117-5420
US

IV. Provider business mailing address

4749 S HOLLADAY BLVD REAR
HOLLADAY UT
84117-5420
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-2952
  • Fax: 801-931-2006
Mailing address:
  • Phone: 801-566-2952
  • Fax: 801-931-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number84597310151
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number84597310151
License Number StateUT

VIII. Authorized Official

Name: MARCI ROUNDY
Title or Position: OWNER
Credential: CNM
Phone: 801-566-2952