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General NPI Number Information
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NPI Number | 1376944942
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Entity Type | Organization
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Legal Business Name | LEGACY DERMATOLOGY
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Dates
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Enumeration Date | 09/14/2014
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Last Update Date | 09/14/2014
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Provider Practice Location Address
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Address Line | 320 W 500 S SUITE 210
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City | BOUNTIFUL
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State | UT
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Zip | 84010-7218
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Country | US
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Telephone | 385-312-0650
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Fax | 385-743-3333
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Provider Business Mailing Address
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Address Line | 1535 LAKEVIEW DR
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City | BOUNTIFUL
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State | UT
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Zip | 84010-1561
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Country | US
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Telephone | 435-770-9247
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. JARED REX HEATON
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Credential | D.O.
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Telephone | 435-770-9247
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 9017921-1204
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License Number State | UT
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