Healthcare Provider Details

I. General information

NPI: 1699075895
Provider Name (Legal Business Name): DANIEL B. VINE, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3980 S 700 E #23
SALT LAKE CITY UT
84107-2188
US

IV. Provider business mailing address

3980 S 700 E #23
SALT LAKE CITY UT
84107-2188
US

V. Phone/Fax

Practice location:
  • Phone: 801-288-1115
  • Fax: 801-288-1116
Mailing address:
  • Phone: 801-288-1115
  • Fax: 801-288-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number171413-1205
License Number StateUT

VIII. Authorized Official

Name: DANIEL B VINE
Title or Position: MD
Credential: MD
Phone: 801-288-1115