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General NPI Number Information
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NPI Number | 1679608582
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Entity Type | Organization
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Legal Business Name | PEACHTREE FAMILY MEDICINE PC
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Dates
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Enumeration Date | 02/22/2007
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Last Update Date | 11/06/2024
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Provider Practice Location Address
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Address Line | 565 W 465 N STE 130
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City | PROVIDENCE
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State | UT
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Zip | 84332-4802
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Country | US
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Telephone | 435-752-5553
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Fax | 435-755-5043
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Provider Business Mailing Address
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Address Line | 169 N GATEWAY DR 170
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City | PROVIDENCE
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State | UT
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Zip | 84332-9855
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Country | US
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Telephone | 435-752-5553
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Fax | 435-755-5043
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Authorized Official
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Title or Position | MD
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Name | VERA B CARLSON
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Credential | MD
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Telephone | 435-752-5553
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5916429-1205
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License Number State | UT
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