Healthcare Provider Details

I. General information

NPI: 1205387008
Provider Name (Legal Business Name): GRANITE PEAKS PATHOLOGY II LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1393 E SEGO LILY DR
SANDY UT
84092-4350
US

IV. Provider business mailing address

1393 E SEGO LILY DR
SANDY UT
84092-4350
US

V. Phone/Fax

Practice location:
  • Phone: 801-619-9000
  • Fax: 801-572-7616
Mailing address:
  • Phone: 801-619-9000
  • Fax: 801-572-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2424607-1205
License Number StateUT

VIII. Authorized Official

Name: ROBERT KYLE BARNETT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 801-619-9000