Healthcare Provider Details

I. General information

NPI: 1750985420
Provider Name (Legal Business Name): ROSE CREEK PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 W 13400 S UNIT B
RIVERTON UT
84096-6412
US

IV. Provider business mailing address

869 E 4500 S # 261
SALT LAKE CITY UT
84107-3049
US

V. Phone/Fax

Practice location:
  • Phone: 801-842-7366
  • Fax:
Mailing address:
  • Phone: 801-842-7366
  • 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: WOODROW CANNON MARRIOTT
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 801-842-7366