Provider Demographics
NPI:1013153311
Name:SERAPHINE MED TAYLORSVILLE, LLC
Entity Type:Organization
Organization Name:SERAPHINE MED TAYLORSVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WENDELL
Authorized Official - Last Name:GNEITING
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:801-966-9907
Mailing Address - Street 1:PO BOX 71218
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-0218
Mailing Address - Country:US
Mailing Address - Phone:801-966-9907
Mailing Address - Fax:801-966-0298
Practice Address - Street 1:6126 SOUTH REDWOOD ROAD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123
Practice Address - Country:US
Practice Address - Phone:801-966-9907
Practice Address - Fax:801-966-0298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty