Healthcare Provider Details

I. General information

NPI: 1750853438
Provider Name (Legal Business Name): CREEK CAPITAL DAYBREAK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4775 W DAYBREAK PKWY STE 103
SOUTH JORDAN UT
84009-5139
US

IV. Provider business mailing address

678 E VINE ST STE 10
MURRAY UT
84107-5500
US

V. Phone/Fax

Practice location:
  • Phone: 801-999-4640
  • Fax:
Mailing address:
  • Phone: 801-918-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARCI NICOL
Title or Position: COO
Credential:
Phone: 801-918-4135