=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780728535
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESERET MEDICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 02/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 560 W FINE DR
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-270-8440
-----------------------------------------------------
Fax | 801-293-9000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 560 WEST FINE DR
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-270-8440
-----------------------------------------------------
Fax | 801-293-9000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. GEREG P BOISJOLIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-544-2002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 5087382-1714
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------