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General NPI Number Information
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NPI Number | 1255665162
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Entity Type | Organization
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Legal Business Name | CONCORD PREMIUM GROUP
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Dates
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Enumeration Date | 09/24/2009
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Last Update Date | 10/16/2009
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Provider Practice Location Address
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Address Line | 356 N 750 W STE D9-213
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City | AMERICAN FORK
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State | UT
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Zip | 84003-1678
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Country | US
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Telephone | 801-300-5159
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Fax |
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Provider Business Mailing Address
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Address Line | 356 N 750 W STE D9-213
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City | AMERICAN FORK
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State | UT
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Zip | 84003-1678
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DANIEL W THOMPSON
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Credential |
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Telephone | 801-300-5159
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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 | 3713101205
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License Number State | UT
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