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General NPI Number Information
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NPI Number | 1801379193
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Entity Type | Organization
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Legal Business Name | COUNTRY CORNER FAMILY MEDICINE
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Dates
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Enumeration Date | 09/12/2018
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Last Update Date | 09/12/2018
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Provider Practice Location Address
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Address Line | 5460 W CLERNATES DR
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City | SALT LAKE CITY
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State | UT
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Zip | 84118-8526
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Country | US
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Telephone | 435-749-1488
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Fax | 801-880-2859
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Provider Business Mailing Address
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Address Line | 5460 W CLERNATES DR
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City | SALT LAKE CITY
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State | UT
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Zip | 84118-8526
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Country | US
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Telephone | 435-749-1488
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Fax | 801-880-2859
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Authorized Official
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Title or Position | OWNER
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Name | KORTNEY MCMULLIN
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Credential | NP
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Telephone | 435-749-1488
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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 |
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License Number State |
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