Provider Demographics
NPI:1194134775
Name:STEP MOUNTAIN MEDICAL
Entity type:Organization
Organization Name:STEP MOUNTAIN MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:PROF
Authorized Official - First Name:KIRT
Authorized Official - Middle Name:WEBB
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNP-C
Authorized Official - Phone:801-446-2460
Mailing Address - Street 1:2332 SOUTH 12600 SOUTH SUITE 2C
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7173
Mailing Address - Country:US
Mailing Address - Phone:801-446-2760
Mailing Address - Fax:
Practice Address - Street 1:2332 W 12600 S STE 2C
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7173
Practice Address - Country:US
Practice Address - Phone:801-446-2760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2114514405261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care