Basic Information
| Provider Information | |||||||||
| NPI: | 1609042837 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RGL MEDICAL SERVICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RGL MOBILE ULTRASOUND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95970 | ||||||||
| Address2: | |||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840950970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013529500 | ||||||||
| FaxNumber: | 8013529502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1561 W 7000 S | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840843556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015689895 | ||||||||
| FaxNumber: | 8013520400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | GORDON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8015689895 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | 116092-5401 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 1376568907 | 05 | UT | MEDICAID |