=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508488008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEXA BODY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2020
-----------------------------------------------------
Last Update Date | 06/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5263 S COMMERCE DR STE 201
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-5306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-274-3392
-----------------------------------------------------
Fax | 801-274-3392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5263 S COMMERCE DR STE 201
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-5306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-274-3392
-----------------------------------------------------
Fax | 801-274-3392
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. BRANDON SHEPPARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-428-8350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0208X
-----------------------------------------------------
Taxonomy Name | Mobile Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1100X
-----------------------------------------------------
Taxonomy Name | Research Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 335V00000X
-----------------------------------------------------
Taxonomy Name | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QG0250X
-----------------------------------------------------
Taxonomy Name | Genetics Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 261QC1800X
-----------------------------------------------------
Taxonomy Name | Corporate Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 133VN1201X
-----------------------------------------------------
Taxonomy Name | Obesity and Weight Management Nutrition Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------