MEDICARE: ROXBURY INSTITUTE SALT LAKE CITY PLLC

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	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1629855937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROXBURY INSTITUTE SALT LAKE CITY PLLC

Provider Business Mailing Address
First Line	:	6344 S 900 E
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84121-2439
Country	:	US
Telephone Number	:	918-851-3715
Fax Number	:

Provider Business Practice Location Address
First Line	:	6344 S 900 E
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84121-2439
Country	:	US
Telephone Number	:	918-851-3715
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. KASSIE L AVILA
Credential	:
Telephone Number	:	918-851-3715

Provider Enumeration Date	:	09/11/2023
Last Update Date	:	09/11/2023

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