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NPI Code Detail

MEDICARE: PEDRO RICO CPSS

MEDICARE: PEDRO RICO CPSS
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
1175T00000XPeer Specialist1646UT

General Provider Information

NPI Number : 1700545761
Entity Type Code : Individual
Provider Name (Legal Business Name) : PEDRO RICO CPSS
Provider Business Mailing Address
First Line : 3269 S MAIN ST STE 230
Second Line :
City : SOUTH SALT LAKE
State : UT
Zip : 84115-3769
Country : US
Telephone Number : 801-935-4447
Fax Number :
Provider Business Practice Location Address
First Line : 3269 S MAIN ST STE 230
Second Line :
City : SOUTH SALT LAKE
State : UT
Zip : 84115-3769
Country : US
Telephone Number : 801-935-4447
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/16/2021
Last Update Date : 12/16/2021

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Directions to “ PEDRO RICO CPSS” Practice Location

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