=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740912260
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVEAL ULTRASOUND STUDIO & SPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2022
-----------------------------------------------------
Last Update Date | 06/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1156 S BENTLEY BLVD STE 1
-----------------------------------------------------
City | CEDAR CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84720-1822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-708-0142
-----------------------------------------------------
Fax | 801-423-1280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1156 S BENTLEY BLVD STE 1
-----------------------------------------------------
City | CEDAR CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84720-1822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-708-0142
-----------------------------------------------------
Fax | 801-423-1280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTRACT MANAGER
-----------------------------------------------------
Name | MARTHA HODGES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-423-8057
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------