Basic Information
| Provider Information | |||||||||
| NPI: | 1528203817 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST JORDAN FAMILY MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6783 S REDWOOD RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840845685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012661088 | ||||||||
| FaxNumber: | 8012661088 | ||||||||
| Practice Location | |||||||||
| Address1: | 6783 S REDWOOD RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840845685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012661088 | ||||||||
| FaxNumber: | 8012661088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2008 | ||||||||
| LastUpdateDate: | 12/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | EARL | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8012661088 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 51103011205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.