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General NPI Number Information
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NPI Number | 1306076625
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Entity Type | Organization
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Legal Business Name | FORT DUCHESNE INDIAN HEALTH CENTER RADIOLOGY
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Dates
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Enumeration Date | 07/21/2009
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Last Update Date | 04/04/2013
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Provider Practice Location Address
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Address Line | 6822 EAST 1000 SOUTH
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City | FORT DUCHESNE
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State | UT
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Zip | 84026
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Country | US
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Telephone | 435-725-6874
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Fax | 435-725-6889
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Provider Business Mailing Address
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Address Line | 6822 EAST 1000 SOUTH
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City | FORT DUCHESNE
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State | UT
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Zip | 84026
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Country | US
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Telephone | 435-725-6874
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Fax | 435-725-6889
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Authorized Official
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Title or Position | CHIEF PHARMACIST
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Name | MR. DELBERT GARY MARTIN
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Credential | RPH
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Telephone | 435-725-6874
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State |
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