| NPI | 1972050532 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RON G MORTENSEN Director 435-660-9446 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: UT 6354409-0160) |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2016-09-01 |