Basic Information
| Provider Information | |||||||||
| NPI: | 1952019846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN ORTHOPAEDICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95590 | ||||||||
| Address2: | |||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840950590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013529500 | ||||||||
| FaxNumber: | 8013527976 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 RENAISSANCE TOWNE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012957200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2022 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | WOOTEN | ||||||||
| AuthorizedOfficialFirstName: | CLINT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/ PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8012957200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.