Provider Demographics
NPI:1629816228
Name:MAPLE MOUNTAIN MEDICAL LLC
Entity type:Organization
Organization Name:MAPLE MOUNTAIN MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:332-330-3903
Mailing Address - Street 1:724 S 1600 W
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664-4347
Mailing Address - Country:US
Mailing Address - Phone:801-515-6048
Mailing Address - Fax:855-848-5748
Practice Address - Street 1:724 S 1600 W
Practice Address - Street 2:
Practice Address - City:MAPLETON
Practice Address - State:UT
Practice Address - Zip Code:84664-4347
Practice Address - Country:US
Practice Address - Phone:801-515-6048
Practice Address - Fax:855-848-5748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty