Provider Demographics
NPI:1750985420
Name:ROSE CREEK PEDIATRICS, LLC
Entity type:Organization
Organization Name:ROSE CREEK PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WOODROW
Authorized Official - Middle Name:CANNON
Authorized Official - Last Name:MARRIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-842-7366
Mailing Address - Street 1:869 E 4500 S # 261
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3049
Mailing Address - Country:US
Mailing Address - Phone:801-842-7366
Mailing Address - Fax:
Practice Address - Street 1:4121 W 13400 S UNIT B
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-6412
Practice Address - Country:US
Practice Address - Phone:801-842-7366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty