Healthcare Provider Details

I. General information

NPI: 1780980391
Provider Name (Legal Business Name): DIAMOND SPRINGS WELLNESS CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E MAIN ST SUITE 101
MIDWAY UT
84049-6806
US

IV. Provider business mailing address

210 E MAIN ST SUITE 101
MIDWAY UT
84049-6806
US

V. Phone/Fax

Practice location:
  • Phone: 435-657-1777
  • Fax: 435-657-0098
Mailing address:
  • Phone: 435-657-1777
  • Fax: 435-657-0098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number180388-1204
License Number StateUT

VIII. Authorized Official

Name: DR. JUDITH S MOORE
Title or Position: OWNER
Credential: D.O.
Phone: 435-657-1777