MEDICARE: INTERMOUNTAIN MEDICAL MONITORING LLC

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	6049595-1204	UT

General Provider Information

NPI Number	:	1134429384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERMOUNTAIN MEDICAL MONITORING LLC

Provider Business Mailing Address
First Line	:	1306 DEERCREST
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037
Country	:	US
Telephone Number	:	801-755-4509
Fax Number	:	801-593-9848

Provider Business Practice Location Address
First Line	:	1306 DEER CREST
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037
Country	:	US
Telephone Number	:	801-755-4509
Fax Number	:	801-593-9848

Authorized Official
Title or Position	:	OWNER/MANAGER/BOARD MEMBER
Name	:	MR. DARIN S STETTLER
Credential	:	D.O.
Telephone Number	:	801-755-4509

Provider Enumeration Date	:	10/21/2010
Last Update Date	:	11/10/2011

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