Healthcare Provider Details

I. General information

NPI: 1174707517
Provider Name (Legal Business Name): SOUTHWEST FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 W 7000 S
WEST JORDAN UT
84084-3431
US

IV. Provider business mailing address

1575 W 7000 S
WEST JORDAN UT
84084-3431
US

V. Phone/Fax

Practice location:
  • Phone: 801-569-9133
  • Fax: 801-569-9103
Mailing address:
  • Phone: 801-569-9133
  • Fax: 801-569-9103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1756991205
License Number StateUT

VIII. Authorized Official

Name: RANDALL L WATSON
Title or Position: MD / OWNER
Credential: MD
Phone: 801-569-9133