Healthcare Provider Details

I. General information

NPI: 1952240392
Provider Name (Legal Business Name): EZRA 1ST MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 S MAIN ST STE 108
SOUTH SALT LAKE UT
84115-5002
US

IV. Provider business mailing address

2480 S MAIN ST STE 108
SOUTH SALT LAKE UT
84115-5002
US

V. Phone/Fax

Practice location:
  • Phone: 385-584-7799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: RYQAIL TAYLOR
Title or Position: OWNER
Credential:
Phone: 725-268-4560