MEDICARE: NORTHERN ROCKIES HOLDINGS

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	332BC3200X	Customized Equipment (DME)	10390897-1714	UT

General Provider Information

NPI Number	:	1649791062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN ROCKIES HOLDINGS

Provider Business Mailing Address
First Line	:	6216 S REDWOOD RD
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84123-6630
Country	:	US
Telephone Number	:	801-974-5555
Fax Number	:

Provider Business Practice Location Address
First Line	:	6216 S REDWOOD RD
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84123-6630
Country	:	US
Telephone Number	:	801-974-5555
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. GARY LEE
Credential	:	D.C.
Telephone Number	:	801-897-9200

Provider Enumeration Date	:	07/06/2017
Last Update Date	:	07/21/2022

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