Provider Demographics
NPI:1063576668
Name:JERRY L. GEARHEART
Entity type:Organization
Organization Name:JERRY L. GEARHEART
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GEARHEART
Authorized Official - Suffix:
Authorized Official - Credentials:MR
Authorized Official - Phone:801-263-3180
Mailing Address - Street 1:4035 S 300 W
Mailing Address - Street 2:#2
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1400
Mailing Address - Country:US
Mailing Address - Phone:801-263-3180
Mailing Address - Fax:801-263-3720
Practice Address - Street 1:4035 S 300 W
Practice Address - Street 2:#2
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1400
Practice Address - Country:US
Practice Address - Phone:801-263-3180
Practice Address - Fax:801-263-3720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT38892332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5565880001Medicare ID - Type UnspecifiedMEDICARE