Healthcare Provider Details

I. General information

NPI: 1497014096
Provider Name (Legal Business Name): UPRI MURRAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 W WINCHESTER ST SUITE 200
MURRAY UT
84107-5607
US

IV. Provider business mailing address

32 W WINCHESTER ST SUITE 100
MURRAY UT
84107-5607
US

V. Phone/Fax

Practice location:
  • Phone: 801-281-0555
  • Fax: 801-281-0444
Mailing address:
  • Phone: 801-281-0555
  • Fax: 801-281-0444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number7112893-1204
License Number StateUT

VIII. Authorized Official

Name: MRS. SHANTELLE DANAE NILLA QURESHI PRATT
Title or Position: MANAGER
Credential:
Phone: 801-327-9336