Provider Demographics
NPI:1508098906
Name:TIMBER RIDGE HOLDINGS LLC
Entity Type:Organization
Organization Name:TIMBER RIDGE HOLDINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNOCKS
Authorized Official - Suffix:
Authorized Official - Credentials:DTP
Authorized Official - Phone:801-698-1160
Mailing Address - Street 1:448 E 5350 S STE B
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TERRACE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-5415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:448 E 5350 S STE B
Practice Address - Street 2:
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405-5415
Practice Address - Country:US
Practice Address - Phone:801-540-4564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty