Healthcare Provider Details

I. General information

NPI: 1508067950
Provider Name (Legal Business Name): PARK CITY HEALTHCARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 BONANZA DRIVE
PARK CITY UT
84060
US

IV. Provider business mailing address

P.O. BOX 680670
PARK CITY UT
84068
US

V. Phone/Fax

Practice location:
  • Phone: 435-649-7640
  • Fax: 435-649-1365
Mailing address:
  • Phone: 435-649-7640
  • Fax: 435-776-9353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN F SWANSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 435-649-7640