MEDICARE: DOCTORS HOUSE CALLS OF UTAH, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QP2300X	Primary Care Clinic/Center
2	363LF0000X	Family Nurse Practitioner
3	213ES0103X	Foot & Ankle Surgery Podiatrist

General Provider Information

NPI Number	:	1487260550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOCTORS HOUSE CALLS OF UTAH, LLC

Provider Business Mailing Address
First Line	:	1552 N CRESTMONT DR STE B
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-2193
Country	:	US
Telephone Number	:	208-957-5532
Fax Number	:	208-985-2260

Provider Business Practice Location Address
First Line	:	1250 E 3900 S STE 440
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1349
Country	:	US
Telephone Number	:	801-791-5710
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	CHRISTINA LYNN PIKE
Credential	:
Telephone Number	:	208-985-2260

Provider Enumeration Date	:	09/23/2020
Last Update Date	:	10/15/2020

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