Provider Demographics
NPI:1770581605
Name:MOUNTAIN WEST FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:MOUNTAIN WEST FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-882-2350
Mailing Address - Street 1:2356 N 400 E
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074
Mailing Address - Country:US
Mailing Address - Phone:435-882-2350
Mailing Address - Fax:435-882-2039
Practice Address - Street 1:2356 N 400 E
Practice Address - Street 2:SUITE 201
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-882-2350
Practice Address - Fax:435-882-2039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005172207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057829Medicare PIN