Provider Demographics
NPI:1952599409
Name:CANYON MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:CANYON MEDICAL GROUP LLC
Other - Org Name:TREEHOUSE PEDIATRICS & FAMILY CARE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WIMMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-750-5599
Mailing Address - Street 1:1624 N 200 E STE 160
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-3175
Mailing Address - Country:US
Mailing Address - Phone:435-750-5599
Mailing Address - Fax:435-750-0861
Practice Address - Street 1:1624 N 200 E STE 160
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-3175
Practice Address - Country:US
Practice Address - Phone:435-750-5599
Practice Address - Fax:435-750-0861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0708814208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528291883001Medicaid
UT528291883001Medicaid
UT005750701Medicare PIN
UTI06230Medicare UPIN
UT528112320001Medicaid
UT528291883001Medicaid