Provider Demographics
NPI:1528203817
Name:WEST JORDAN FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:WEST JORDAN FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:J
Authorized Official - Last Name:EARL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-266-1088
Mailing Address - Street 1:6783 S REDWOOD RD STE 103
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-5685
Mailing Address - Country:US
Mailing Address - Phone:801-266-1088
Mailing Address - Fax:801-266-1088
Practice Address - Street 1:6783 S REDWOOD RD STE 103
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-5685
Practice Address - Country:US
Practice Address - Phone:801-266-1088
Practice Address - Fax:801-266-1088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51103011205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty