=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962989244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESERET MEDICAL ASSOCIATES PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2018
-----------------------------------------------------
Last Update Date | 03/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6410 S KINGS RANCH RD STE 1
-----------------------------------------------------
City | GOLD CANYON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-981-3000
-----------------------------------------------------
Fax | 480-325-3614
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6410 S KINGS RANCH RD STE 1
-----------------------------------------------------
City | GOLD CANYON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85118-7352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-761-2500
-----------------------------------------------------
Fax | 480-378-2743
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT C ALLEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 480-761-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------