Healthcare Provider Details

I. General information

NPI: 1447609987
Provider Name (Legal Business Name): GRANGER MEDICAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 S FASHION BLVD SUITE 140
MURRAY UT
84107
US

IV. Provider business mailing address

7181 S CAMPUS VIEW DR
WEST JORDAN UT
84084-4312
US

V. Phone/Fax

Practice location:
  • Phone: 801-260-5864
  • Fax: 801-260-5865
Mailing address:
  • Phone: 801-965-3505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY JANE PENNINGTON
Title or Position: PRESIDENT
Credential:
Phone: 801-965-3600