Provider Demographics
NPI:1437671583
Name:KG MEDICAL CONSULTING
Entity Type:Organization
Organization Name:KG MEDICAL CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:Q
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-430-0282
Mailing Address - Street 1:2040 E MURRAY HOLLADAY RD STE 115
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5139
Mailing Address - Country:US
Mailing Address - Phone:801-430-0282
Mailing Address - Fax:801-508-2273
Practice Address - Street 1:231 E 200 N
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-1742
Practice Address - Country:US
Practice Address - Phone:801-319-2772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-11
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7382930-0160293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory