Provider Demographics
NPI:1093330698
Name:GRANGER MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:GRANGER MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-965-3505
Mailing Address - Street 1:7181 S CAMPUS VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-4312
Mailing Address - Country:US
Mailing Address - Phone:801-965-3505
Mailing Address - Fax:
Practice Address - Street 1:5323 S WOODROW ST STE 203
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5851
Practice Address - Country:US
Practice Address - Phone:801-266-8664
Practice Address - Fax:801-264-9031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANGER MEDICAL CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site