Healthcare Provider Details

I. General information

NPI: 1649541699
Provider Name (Legal Business Name): GRANGER MEDICAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1288 W 12700 S
RIVERTON UT
84065-6794
US

IV. Provider business mailing address

3725 W 4100 S
WEST VALLEY CITY UT
84120-5530
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-3500
  • Fax: 801-253-5859
Mailing address:
  • Phone: 801-965-3505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANNE WHITAKER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 801-965-3505