Healthcare Provider Details

I. General information

NPI: 1124762281
Provider Name (Legal Business Name): METRODORA CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 05/02/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 S MARKET ST
WEST VALLEY CITY UT
84119-3635
US

IV. Provider business mailing address

3535 S MARKET ST
WEST VALLEY CITY UT
84119-3635
US

V. Phone/Fax

Practice location:
  • Phone: 385-430-1430
  • Fax:
Mailing address:
  • Phone: 385-430-1431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY BITNER
Title or Position: MEDICAL STAFF OFFICE
Credential:
Phone: 385-430-1430