Healthcare Provider Details

I. General information

NPI: 1871203414
Provider Name (Legal Business Name): NOORDA COLLEGE OF OSTEOPATHIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2162 SOUTH 180 EAST, STE 1000
PROVO UT
84606
US

IV. Provider business mailing address

2162 S 180 E STE 1000
PROVO UT
84606-7370
US

V. Phone/Fax

Practice location:
  • Phone: 385-380-3425
  • Fax:
Mailing address:
  • Phone: 385-380-3425
  • Fax: 855-873-2517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER SHUMWAY
Title or Position: DIRECTOR OF CLINICAL OPERATIONS
Credential:
Phone: 801-380-0015