Healthcare Provider Details

I. General information

NPI: 1588162911
Provider Name (Legal Business Name): DESERT EDGE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1664 S DIXIE DR STE D201
ST GEORGE UT
84770
US

IV. Provider business mailing address

93 W ORCHARD LN
WASHINGTON UT
84780-2072
US

V. Phone/Fax

Practice location:
  • Phone: 435-656-2995
  • Fax:
Mailing address:
  • Phone: 435-862-5925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: RYAN T BORROWMAN
Title or Position: OWNER
Credential: DNP
Phone: 435-656-2995