MEDICARE: MRS. MOLLY LEROY AUD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	4830696-4101	UT

General Provider Information

NPI Number	:	1033442959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MOLLY LEROY AUD

Provider Business Mailing Address
First Line	:	8806 S REDWOOD RD
Second Line	:	SUITE 103
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-9337
Country	:	US
Telephone Number	:	801-495-4800
Fax Number	:	801-432-7107

Provider Business Practice Location Address
First Line	:	8806 S REDWOOD RD
Second Line	:	SUITE 103
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-9337
Country	:	US
Telephone Number	:	801-495-4800
Fax Number	:	801-432-7107

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2009
Last Update Date	:	09/09/2009

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