Healthcare Provider Details

I. General information

NPI: 1629816228
Provider Name (Legal Business Name): MAPLE MOUNTAIN MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/17/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 S 1600 W
MAPLETON UT
84664-4347
US

IV. Provider business mailing address

724 S 1600 W
MAPLETON UT
84664-4347
US

V. Phone/Fax

Practice location:
  • Phone: 801-515-6048
  • Fax: 855-848-5748
Mailing address:
  • Phone: 801-515-6048
  • Fax: 855-848-5748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JOHNSON
Title or Position: CEO
Credential:
Phone: 332-330-3903