Provider Demographics
NPI:1053318709
Name:MEDICOR, LLC
Entity Type:Organization
Organization Name:MEDICOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:FROST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-942-5543
Mailing Address - Street 1:3652 BRIGHTON POINT DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-5555
Mailing Address - Country:US
Mailing Address - Phone:801-942-5543
Mailing Address - Fax:801-944-4877
Practice Address - Street 1:2469 FORT UNION BLVD
Practice Address - Street 2:STE 105
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-3343
Practice Address - Country:US
Practice Address - Phone:801-942-5543
Practice Address - Fax:801-944-4877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870454846001Medicaid
UT870454846001Medicaid