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General NPI Number Information
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NPI Number | 1164221974
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Entity Type | Organization
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Legal Business Name | GRATEFUL DIRECT PRIMARY CARE PLLC
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Dates
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Enumeration Date | 03/12/2025
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Last Update Date | 03/12/2025
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Provider Practice Location Address
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Address Line | 8541 S REDWOOD RD STE B1
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City | WEST JORDAN
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State | UT
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Zip | 84088-9323
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Country | US
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Telephone | 801-706-0171
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Fax |
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Provider Business Mailing Address
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Address Line | 8541 S REDWOOD RD STE B1
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City | WEST JORDAN
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State | UT
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Zip | 84088-9323
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Country | US
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Telephone | 801-706-0171
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Fax |
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Authorized Official
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Title or Position | CLINIC MANAGER
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Name | WESLEY BRIAN WALSMAN
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Credential |
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Telephone | 956-639-0644
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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