Healthcare Provider Details

I. General information

NPI: 1649791062
Provider Name (Legal Business Name): NORTHERN ROCKIES HOLDINGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6216 S REDWOOD RD
SLC UT
84123-6630
US

IV. Provider business mailing address

6216 S REDWOOD RD
SLC UT
84123-6630
US

V. Phone/Fax

Practice location:
  • Phone: 801-974-5555
  • Fax:
Mailing address:
  • Phone: 801-974-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number10390897-1714
License Number StateUT

VIII. Authorized Official

Name: DR. GARY LEE
Title or Position: MANAGING MEMBER
Credential: D.C.
Phone: 801-897-9200