Healthcare Provider Details

I. General information

NPI: 1255858734
Provider Name (Legal Business Name): FJM BASECAMP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 07/21/2022
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S STATE ST STE 208
SALT LAKE CITY UT
84111-1558
US

IV. Provider business mailing address

560 S 300 E STE 275
SALT LAKE CITY UT
84111-3586
US

V. Phone/Fax

Practice location:
  • Phone: 801-821-5454
  • Fax: 801-821-5455
Mailing address:
  • Phone: 801-441-1002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number70786441205
License Number StateUT

VIII. Authorized Official

Name: DARCE A LATSIS
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 801-441-1002