Healthcare Provider Details

I. General information

NPI: 1710980354
Provider Name (Legal Business Name): ROCKY MOUNTAIN RETINA CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 S 700 E STE 200
SALT LAKE CITY UT
84107-3000
US

IV. Provider business mailing address

4400 S 700 E STE 200
SALT LAKE CITY UT
84107-3000
US

V. Phone/Fax

Practice location:
  • Phone: 801-264-4444
  • Fax: 801-281-2383
Mailing address:
  • Phone: 801-264-4444
  • Fax: 801-281-2383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MINDY THORNE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 801-264-4444