Basic Information
| Provider Information | |||||||||
| NPI: | 1942225461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY MOUNTAIN CARE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 307 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840110307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887006907 | ||||||||
| FaxNumber: | 8012946917 | ||||||||
| Practice Location | |||||||||
| Address1: | 1775 S 4130 W | ||||||||
| Address2: | #A | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841044812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019757799 | ||||||||
| FaxNumber: | 8019757460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RHUDY | ||||||||
| AuthorizedOfficialFirstName: | JACKSON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8887006907 | ||||||||
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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 | 156694-1205 | UT | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | 5932534-4405 | UT | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.