Healthcare Provider Details

I. General information

NPI: 1306275227
Provider Name (Legal Business Name): JORDAN RIDGE FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4071 S 4000 W
WEST VALLEY CITY UT
84120-4143
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 801-515-7196
  • Fax:
Mailing address:
  • Phone: 702-560-2916
  • Fax: 702-560-2928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN RHODES
Title or Position: MD
Credential:
Phone: 702-480-2550