Provider Demographics
NPI:1780728535
Name:DESERET MEDICAL INC
Entity type:Organization
Organization Name:DESERET MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GEREG
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOISJOLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-544-2002
Mailing Address - Street 1:560 WEST FINE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115
Mailing Address - Country:US
Mailing Address - Phone:801-270-8440
Mailing Address - Fax:801-293-9000
Practice Address - Street 1:560 W FINE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115
Practice Address - Country:US
Practice Address - Phone:801-270-8440
Practice Address - Fax:801-293-9000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
UT5087382-1714332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT346547OtherDESERET MUTUAL BENEFITS A
UT1214900001Medicare ID - Type Unspecified