Provider Demographics
NPI:1174539142
Name:BOUNTIFUL FAMILY HEALTHCARE
Entity type:Organization
Organization Name:BOUNTIFUL FAMILY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:801-298-3812
Mailing Address - Street 1:65 W 400 N STE 200B
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6475
Mailing Address - Country:US
Mailing Address - Phone:801-298-3812
Mailing Address - Fax:877-450-7813
Practice Address - Street 1:65 W 400 N STE 200B
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6475
Practice Address - Country:US
Practice Address - Phone:801-298-3812
Practice Address - Fax:877-450-7813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT30835038904207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT476806920005Medicaid
UT000057742Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
UT000012309Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NO.
UT476806920005Medicaid