MEDICARE: JORDAN RIDGE FAMILY MEDICINE 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	207R00000X	Internal Medicine Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1306275227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JORDAN RIDGE FAMILY MEDICINE LLC

Provider Business Mailing Address
First Line	:	PO BOX 35380
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89133-5380
Country	:	US
Telephone Number	:	702-560-2916
Fax Number	:	702-560-2928

Provider Business Practice Location Address
First Line	:	4071 S 4000 W
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-4143
Country	:	US
Telephone Number	:	801-515-7196
Fax Number	:

Authorized Official
Title or Position	:	MD
Name	:	JOHN RHODES
Credential	:
Telephone Number	:	702-480-2550

Provider Enumeration Date	:	11/02/2013
Last Update Date	:	08/09/2023

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