Healthcare Provider Details

I. General information

NPI: 1699311209
Provider Name (Legal Business Name): PREMIER PROVIDER HEALTH UTAH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5475 S 500 E
OGDEN UT
84405-6905
US

IV. Provider business mailing address

1 CHISHOLM TRAIL RD STE 5200
ROUND ROCK TX
78681-5090
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-2111
  • Fax:
Mailing address:
  • Phone: 512-202-3830
  • Fax: 512-354-1106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NORA LOPEZ
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 346-239-9469