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General NPI Number Information
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NPI Number | 1770581605
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Entity Type | Organization
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Legal Business Name | MOUNTAIN WEST FAMILY PRACTICE LLC
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Dates
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Enumeration Date | 07/13/2005
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Last Update Date | 11/24/2020
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Provider Practice Location Address
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Address Line | 2356 N 400 E SUITE 201
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City | TOOELE
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State | UT
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Zip | 84074
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Country | US
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Telephone | 435-882-2350
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Fax | 435-882-2039
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Provider Business Mailing Address
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Address Line | 2356 N 400 E SUITE 201
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City | TOOELE
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State | UT
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Zip | 84074
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Country | US
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Telephone | 435-882-2350
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Fax | 435-882-2039
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Authorized Official
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Title or Position | PRESIDENT
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Name | BLAKE BEAZER
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Credential | MD
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Telephone | 435-882-2350
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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 | 2005172
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License Number State | UT
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