Healthcare Provider Details

I. General information

NPI: 1841872728
Provider Name (Legal Business Name): JORDAN RIDGE FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 EAST SEGO LANE SUITE 100
SANDY UT
84092
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 385-274-3959
  • Fax: 385-274-3970
Mailing address:
  • Phone: 702-579-3253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0207X
TaxonomyMobile Mammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EMILY CASTILLO
Title or Position: MANAGER
Credential:
Phone: 702-480-2550