Healthcare Provider Details

I. General information

NPI: 1568191526
Provider Name (Legal Business Name): FIRSTLINE IV THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 S DONLEE DR
SAINT GEORGE UT
84770-5231
US

IV. Provider business mailing address

1150 E PINE VALLEY ST
WASHINGTON UT
84780-8863
US

V. Phone/Fax

Practice location:
  • Phone: 435-922-1217
  • Fax:
Mailing address:
  • Phone: 435-922-1217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KERIANN WALL MCKEON
Title or Position: OFFICE MANAGER
Credential:
Phone: 435-922-1217