Healthcare Provider Details

I. General information

NPI: 1508079310
Provider Name (Legal Business Name): TWIN PEAKS MEDICAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5117 W 8180 S
WEST JORDAN UT
84081-5922
US

IV. Provider business mailing address

PO BOX 71043
SALT LAKE CITY UT
84171-0043
US

V. Phone/Fax

Practice location:
  • Phone: 801-879-4982
  • Fax: 801-446-1474
Mailing address:
  • Phone: 801-879-4982
  • Fax: 801-446-1474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number268117-0501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY D JOHNSON
Title or Position: OWNER
Credential: MD
Phone: 801-879-4982