Healthcare Provider Details

I. General information

NPI: 1487986030
Provider Name (Legal Business Name): LARRA ELENA MURDOCK CSI, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 SUN PEAK DR SUITE 140-B
PARK CITY UT
84098-6725
US

IV. Provider business mailing address

571 N 250 W
HEBER CITY UT
84032-1450
US

V. Phone/Fax

Practice location:
  • Phone: 435-901-0501
  • Fax:
Mailing address:
  • Phone: 435-901-0501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5009964-4701
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number5009964-4701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: