Healthcare Provider Details

I. General information

NPI: 1841393972
Provider Name (Legal Business Name): INTERMOUNTAIN ALLERGY & IMMUNOLOGY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5929 FASHION POINT DR STE 101
SOUTH OGDEN UT
84403-4672
US

IV. Provider business mailing address

5929 FASHION POINT DR STE 101
SOUTH OGDEN UT
84403-4672
US

V. Phone/Fax

Practice location:
  • Phone: 801-476-0052
  • Fax: 801-476-0064
Mailing address:
  • Phone: 801-476-0052
  • Fax: 801-476-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: DUANE HARRIS
Title or Position: PARTNER
Credential:
Phone: 801-363-4071