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General NPI Number Information
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NPI Number | 1689310948
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Entity Type | Organization
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Legal Business Name | UTAH MODERN MEDICAL LLC
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Dates
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Enumeration Date | 05/10/2022
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Last Update Date | 02/10/2025
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Provider Practice Location Address
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Address Line | 3300 N ASHTON BLVD STE 450
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City | LEHI
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State | UT
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Zip | 84043-6153
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Country | US
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Telephone | 385-455-7170
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Fax | 888-823-5887
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Provider Business Mailing Address
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Address Line | 3300 N ASHTON BLVD STE 450
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City | LEHI
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State | UT
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Zip | 84043-6153
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Country | US
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Telephone | 385-455-7170
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Fax | 888-823-5887
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Authorized Official
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Title or Position | OWNER
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Name | MR. DAVE BULLOCK
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Credential |
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Telephone | 385-455-7170
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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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 | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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