Provider Demographics
NPI:1104060714
Name:COMPREHENSIVE MEDICAL MANAGEMENT, PC
Entity type:Organization
Organization Name:COMPREHENSIVE MEDICAL MANAGEMENT, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-955-1232
Mailing Address - Street 1:4052 W PIONEER PARKWAY
Mailing Address - Street 2:SUITE 208
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120
Mailing Address - Country:US
Mailing Address - Phone:801-955-1232
Mailing Address - Fax:801-955-1543
Practice Address - Street 1:4052 W PIONEER PARKWAY
Practice Address - Street 2:SUITE 208
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120
Practice Address - Country:US
Practice Address - Phone:801-955-1232
Practice Address - Fax:801-955-1543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT89180152-12052081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE98197Medicare UPIN