Provider Demographics
NPI:1023263969
Name:MOUNTAIN PEAKS FAMILY PRACTICE LC
Entity type:Organization
Organization Name:MOUNTAIN PEAKS FAMILY PRACTICE LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GUY
Authorized Official - Last Name:DURRANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-724-9840
Mailing Address - Street 1:501 E 770 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-4102
Mailing Address - Country:US
Mailing Address - Phone:801-724-9840
Mailing Address - Fax:801-235-1909
Practice Address - Street 1:501 E 770 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4102
Practice Address - Country:US
Practice Address - Phone:801-724-9840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1447332465Medicaid