Healthcare Provider Details

I. General information

NPI: 1811107337
Provider Name (Legal Business Name): MEDICAL MARTS,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 WASHINGTON BLVD
OGDEN UT
84404-4949
US

IV. Provider business mailing address

2685 S RAINBOW BLVD SUITE 112
LAS VEGAS NV
89146-5182
US

V. Phone/Fax

Practice location:
  • Phone: 801-392-7100
  • Fax:
Mailing address:
  • Phone: 702-562-0458
  • Fax: 847-256-1951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number6571785-8019
License Number StateUT

VIII. Authorized Official

Name: MR. PAUL MATHEWSON
Title or Position: DIRECTOR OF PAYER RELATIONS
Credential:
Phone: 702-562-0458