Healthcare Provider Details

I. General information

NPI: 1104567882
Provider Name (Legal Business Name): GRANGER MEDICAL SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12391 S 4000 W
RIVERTON UT
84096-7012
US

IV. Provider business mailing address

7181 S CAMPUS VIEW DR STE 200
WEST JORDAN UT
84084-4312
US

V. Phone/Fax

Practice location:
  • Phone: 801-302-1700
  • Fax:
Mailing address:
  • Phone: 801-965-3505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY JANE PENNINGTON
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 801-965-3600