Provider Demographics
NPI:1073811733
Name:GRANGER MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:GRANGER MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-965-3600
Mailing Address - Street 1:2965 W 3500 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3602
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:
Practice Address - Street 1:2356 N 400 E STE 201
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3409
Practice Address - Country:US
Practice Address - Phone:801-352-5900
Practice Address - Fax:801-352-5914
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANGER MEDICAL CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-04
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000004880Medicare PIN