Healthcare Provider Details

I. General information

NPI: 1801417597
Provider Name (Legal Business Name): CREEK CAPITAL-RIVERTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 E FORT UNION BLVD STE 100
MIDVALE UT
84047-1890
US

IV. Provider business mailing address

1275 E FORT UNION BLVD STE 100
MIDVALE UT
84047-1890
US

V. Phone/Fax

Practice location:
  • Phone: 801-918-4135
  • Fax:
Mailing address:
  • Phone: 801-918-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARCI NICOL
Title or Position: VP
Credential:
Phone: 801-918-4135