MEDICARE: BLUE ROCK PROPERTIES 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	247100000X	Radiologic Technologist	20022355	UT

General Provider Information

NPI Number	:	1467606137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE ROCK PROPERTIES LLC

Provider Business Mailing Address
First Line	:	280 RIVER PARK DR
Second Line	:	100
City	:	PROVO
State	:	UT
Zip	:	84604-5764
Country	:	US
Telephone Number	:	801-437-4895
Fax Number	:	801-229-1003

Provider Business Practice Location Address
First Line	:	130 S 400 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-1145
Country	:	US
Telephone Number	:	801-456-7226
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MARTHA HODGES
Credential	:
Telephone Number	:	801-437-4895

Provider Enumeration Date	:	11/07/2008
Last Update Date	:	03/27/2009

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Directions to “BLUE ROCK PROPERTIES LLC ” Practice Location

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