Healthcare Provider Details

I. General information

NPI: 1679420160
Provider Name (Legal Business Name): QUANTUM PROVIDER SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 W BROADWAY FL 7
SALT LAKE CITY UT
84101-2060
US

IV. Provider business mailing address

10 W BROADWAY
SALT LAKE CITY UT
84101-2002
US

V. Phone/Fax

Practice location:
  • Phone: 323-251-7313
  • Fax:
Mailing address:
  • Phone: 323-251-7313
  • 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: SIRAJE KAKOOZA
Title or Position: MEMBER
Credential:
Phone: 323-251-7313