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General NPI Number Information
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NPI Number | 1902286297
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Entity Type | Organization
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Legal Business Name | BIORESTORATION MEDICAL
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Dates
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Enumeration Date | 06/02/2015
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Last Update Date | 06/02/2015
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Provider Practice Location Address
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Address Line | 12340 S 450 E
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City | DRAPER
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State | UT
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Zip | 84020-8154
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Country | US
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Telephone | 801-501-9797
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Fax |
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Provider Business Mailing Address
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Address Line | 12340 S 450 E
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City | DRAPER
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State | UT
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Zip | 84020-8154
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Country | US
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Telephone | 801-501-9797
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | JEFFREY S NELSON
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Credential | D.O.
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Telephone | 801-501-9797
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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 | 6543672-8906
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License Number State | UT
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