Healthcare Provider Details

I. General information

NPI: 1578937801
Provider Name (Legal Business Name): CROSS COUNTRY HOLDINGS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WASHINGTON BLVD STE 104
OGDEN UT
84401-6849
US

IV. Provider business mailing address

1900 WASHINGTON BLVD STE 104
OGDEN UT
84401-6849
US

V. Phone/Fax

Practice location:
  • Phone: 801-612-1085
  • Fax: 801-337-1104
Mailing address:
  • Phone: 801-612-1085
  • Fax: 801-337-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9579184-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7387084-1202
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7387085-1202
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4891288-1204
License Number StateUT

VIII. Authorized Official

Name: JENNIFER KOCOUR
Title or Position: PRESIDENT
Credential: D.C.
Phone: 801-689-0123