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General NPI Number Information
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NPI Number | 1750985420
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Entity Type | Organization
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Legal Business Name | ROSE CREEK PEDIATRICS, LLC
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Dates
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Enumeration Date | 11/24/2020
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Last Update Date | 11/24/2020
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Provider Practice Location Address
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Address Line | 4121 W 13400 S UNIT B
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City | RIVERTON
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State | UT
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Zip | 84096-6412
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Country | US
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Telephone | 801-842-7366
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Fax |
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Provider Business Mailing Address
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Address Line | 869 E 4500 S # 261
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City | SALT LAKE CITY
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State | UT
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Zip | 84107-3049
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Country | US
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Telephone | 801-842-7366
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | WOODROW CANNON MARRIOTT
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Credential | MD
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Telephone | 801-842-7366
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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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