Healthcare Provider Details

I. General information

NPI: 1497500714
Provider Name (Legal Business Name): MEDICALLY DIRECTED CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2024
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4465 S 900 E STE 275
MILLCREEK UT
84124-2644
US

IV. Provider business mailing address

4465 S 900 E STE 275
MILLCREEK UT
84124-2644
US

V. Phone/Fax

Practice location:
  • Phone: 385-213-0086
  • Fax: 385-508-3796
Mailing address:
  • Phone: 385-213-0086
  • Fax: 385-508-3796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIANA GARCIA
Title or Position: CLINIC DIRECTOR
Credential:
Phone: 801-560-2520