Healthcare Provider Details

I. General information

NPI: 1518583566
Provider Name (Legal Business Name): ALEXANDERS FITNESS COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 S 1060 W
LINDON UT
84042-1606
US

IV. Provider business mailing address

1160 E 3900 S STE 4000
SALT LAKE CITY UT
84124-1264
US

V. Phone/Fax

Practice location:
  • Phone: 385-306-1222
  • Fax:
Mailing address:
  • Phone: 801-262-8486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY GRAFF RANDLE
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 802-262-8486