Healthcare Provider Details

I. General information

NPI: 1548032568
Provider Name (Legal Business Name): BONFIRE REVENUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5547 S WALDEN GLEN DR
MURRAY UT
84123-7942
US

IV. Provider business mailing address

8977 S 1300 W # 2046
WEST JORDAN UT
84088-9274
US

V. Phone/Fax

Practice location:
  • Phone: 877-647-2455
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PRESTON BOUTSIS
Title or Position: CMO
Credential:
Phone: 877-647-2455