Healthcare Provider Details

I. General information

NPI: 1205448057
Provider Name (Legal Business Name): PUZZLE PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N HOSPITAL DR STE 3
PRICE UT
84501-4222
US

IV. Provider business mailing address

312 N 700 E
PRICE UT
84501-2702
US

V. Phone/Fax

Practice location:
  • Phone: 208-407-0691
  • Fax:
Mailing address:
  • Phone: 208-407-0691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES T CRIDDLE
Title or Position: DO/OWNER
Credential: DO
Phone: 208-407-0691