Healthcare Provider Details

I. General information

NPI: 1033159488
Provider Name (Legal Business Name): SOUTH MOUNTAIN DIALYSIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10969 S RIVER FRONT PKWY
SOUTH JORDAN UT
84095-3538
US

IV. Provider business mailing address

10969 S RIVER FRONT PKWY
SOUTH JORDAN UT
84095-3538
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-9696
  • Fax: 801-253-3303
Mailing address:
  • Phone: 801-253-9696
  • Fax: 801-253-3303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARRY L. BLANTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 781-699-9000