Healthcare Provider Details

I. General information

NPI: 1982965034
Provider Name (Legal Business Name): KRISTEN HAAS BLACK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3723 W 12600 S STE 360
RIVERTON UT
84065-7296
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-285-4700
  • Fax:
Mailing address:
  • Phone: 801-285-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5101019941
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number9732284-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: