MEDICARE: CREEK CAPITAL DAYBREAK 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1750853438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREEK CAPITAL DAYBREAK LLC

Provider Business Mailing Address
First Line	:	678 E VINE ST STE 10
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-5500
Country	:	US
Telephone Number	:	801-918-4135
Fax Number	:

Provider Business Practice Location Address
First Line	:	4775 W DAYBREAK PKWY STE 103
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84009-5139
Country	:	US
Telephone Number	:	801-999-4640
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	MARCI NICOL
Credential	:
Telephone Number	:	801-918-4135

Provider Enumeration Date	:	12/19/2018
Last Update Date	:	12/19/2018

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Directions to “CREEK CAPITAL DAYBREAK LLC ” Practice Location

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