Provider Demographics
NPI:1457538043
Name:MKG ENTERPRISES
Entity Type:Organization
Organization Name:MKG ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:GRIFFETH
Authorized Official - Suffix:VII
Authorized Official - Credentials:MD
Authorized Official - Phone:435-843-8333
Mailing Address - Street 1:PO BOX 1140
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-1140
Mailing Address - Country:US
Mailing Address - Phone:435-843-8333
Mailing Address - Fax:435-843-8334
Practice Address - Street 1:196 E 2000 N
Practice Address - Street 2:SUITE 109
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9335
Practice Address - Country:US
Practice Address - Phone:435-843-8333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MKG ENTERPRISES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5277420001Medicare NSC