Healthcare Provider Details

I. General information

NPI: 1649790080
Provider Name (Legal Business Name): JUPITER MEDICAL II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 06/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7724 S 5600 W STE 102
WEST JORDAN UT
84081-5415
US

IV. Provider business mailing address

21 WHITE HILL RD
COLD SPRING HARBOR NY
11724-1211
US

V. Phone/Fax

Practice location:
  • Phone: 801-432-8480
  • Fax: 435-731-8328
Mailing address:
  • Phone: 617-571-3680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRYAN KNEPPER
Title or Position: OWNER
Credential:
Phone: 617-571-3680