Healthcare Provider Details

I. General information

NPI: 1093330698
Provider Name (Legal Business Name): GRANGER MEDICAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 E 4500 S
MURRAY UT
84107-3906
US

IV. Provider business mailing address

2965 W 3500 S
WEST VALLEY CITY UT
84119-3602
US

V. Phone/Fax

Practice location:
  • Phone: 801-965-3600
  • Fax:
Mailing address:
  • Phone: 801-965-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: ANNE WHITAKER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 801-965-3505