Provider Demographics
NPI:1962974493
Name:DIABETES AND WOUND CARE CLINIC OF ST GEORGE
Entity type:Organization
Organization Name:DIABETES AND WOUND CARE CLINIC OF ST GEORGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-860-9240
Mailing Address - Street 1:1054 E RIVERSIDE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4829
Mailing Address - Country:US
Mailing Address - Phone:435-574-5123
Mailing Address - Fax:435-634-8894
Practice Address - Street 1:1054 E RIVERSIDE DR STE 201
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4829
Practice Address - Country:US
Practice Address - Phone:435-574-5123
Practice Address - Fax:435-634-8894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-21
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3010016Medicaid