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General NPI Number Information
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NPI Number | 1649541699
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Entity Type | Organization
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Legal Business Name | GRANGER MEDICAL CLINIC, PC
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Dates
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Enumeration Date | 01/23/2012
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Last Update Date | 03/02/2015
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Provider Practice Location Address
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Address Line | 1288 W 12700 S
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City | RIVERTON
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State | UT
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Zip | 84065-6794
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Country | US
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Telephone | 801-253-3500
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Fax | 801-253-5859
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Provider Business Mailing Address
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Address Line | 3725 W 4100 S
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City | WEST VALLEY CITY
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State | UT
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Zip | 84120-5530
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Country | US
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Telephone | 801-965-3505
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | MRS. ANNE WHITAKER
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Credential |
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Telephone | 801-965-3505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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