Healthcare Provider Details

I. General information

NPI: 1730554734
Provider Name (Legal Business Name): BLUE ROCK NEUROLOGICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3152 N UNIVERSITY AVE STE 220
PROVO UT
84604-4746
US

IV. Provider business mailing address

3152 N UNIVERSITY AVE STE 220
PROVO UT
84604-4746
US

V. Phone/Fax

Practice location:
  • Phone: 801-229-1014
  • Fax: 801-229-1067
Mailing address:
  • Phone: 801-229-1014
  • Fax: 801-229-1067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateUT
# 5
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateUT

VIII. Authorized Official

Name: WENDELL GIBBY
Title or Position: MANAGER/OWNER
Credential: MD
Phone: 801-229-1014