Healthcare Provider Details

I. General information

NPI: 1700503182
Provider Name (Legal Business Name): PRIMARY HEALTHCARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6095 S FASHION BLVD STE 220
MURRAY UT
84107-7393
US

IV. Provider business mailing address

6095 S FASHION BLVD STE 220
MURRAY UT
84107-7393
US

V. Phone/Fax

Practice location:
  • Phone: 801-758-8735
  • Fax: 801-769-3991
Mailing address:
  • Phone: 801-758-8735
  • Fax: 801-769-3991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN MANGUM
Title or Position: CEO/PHYSICIAN
Credential: DO
Phone: 801-758-8735