Healthcare Provider Details

I. General information

NPI: 1770102899
Provider Name (Legal Business Name): ERICA T MENINNO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W 7200 S STE A
MIDVALE UT
84047-1043
US

IV. Provider business mailing address

2621 S 3270 W
WEST VALLEY CITY UT
84119-1119
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-5494
  • Fax: 877-497-4661
Mailing address:
  • Phone: 852-612-6143
  • Fax: 877-497-4661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13214887-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: