Healthcare Provider Details

I. General information

NPI: 1932216652
Provider Name (Legal Business Name): GRANGER MEDICAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E 3900 S SUITE #C130
SALT LAKE CITY UT
84124-1214
US

IV. Provider business mailing address

1121 E 3900 S SUITE #C130
SALT LAKE CITY UT
84124-1214
US

V. Phone/Fax

Practice location:
  • Phone: 801-281-1300
  • Fax:
Mailing address:
  • Phone: 801-281-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1773041205
License Number StateUT

VIII. Authorized Official

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