MEDICARE: MOTERUM SPECIALTY SERVICES LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician
2	225100000X	Physical Therapist
3	225X00000X	Occupational Therapist
4	2081P0301X	Brain Injury Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number	:	1467022863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOTERUM SPECIALTY SERVICES LLC

Provider Business Mailing Address
First Line	:	2757 S 300 W
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84115-2933
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2757 S 300 W
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84115-2933
Country	:	US
Telephone Number	:	678-592-3447
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DAVID HUIZENGA
Credential	:
Telephone Number	:	678-592-3447

Provider Enumeration Date	:	06/28/2021
Last Update Date	:	07/06/2021

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