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General NPI Number Information
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NPI Number | 1548032568
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Entity Type | Organization
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Legal Business Name | BONFIRE REVENUE
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Dates
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Enumeration Date | 10/24/2023
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Last Update Date | 10/24/2023
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Provider Practice Location Address
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Address Line | 5547 S WALDEN GLEN DR
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City | MURRAY
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State | UT
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Zip | 84123-7942
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Country | US
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Telephone | 877-647-2455
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Fax |
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Provider Business Mailing Address
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Address Line | 8977 S 1300 W # 2046
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City | WEST JORDAN
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State | UT
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Zip | 84088-9274
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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 | CMO
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Name | PRESTON BOUTSIS
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Credential |
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Telephone | 877-647-2455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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