Provider Demographics
NPI:1558766477
Name:JORDAN VALLEY DERMATOLOGY CENTER LLC
Entity Type:Organization
Organization Name:JORDAN VALLEY DERMATOLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-569-1456
Mailing Address - Street 1:3570 W 9000 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8869
Mailing Address - Country:US
Mailing Address - Phone:801-569-1456
Mailing Address - Fax:801-565-7931
Practice Address - Street 1:3570 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8869
Practice Address - Country:US
Practice Address - Phone:801-569-1456
Practice Address - Fax:801-565-7931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1756931205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty