Srs-Provo, LLC

NPI #1679147904 in Provo, Utah

Provider Information

NPI Number: 1679147904
Entity Type: Organization
Organization Name: Srs-Provo, LLC
Primary Specialty: Clinic/Center - End-Stage Renal Disease (ESRD) Treatment
Enumeration Date: May 20, 2021
Last Updated: May 21, 2021

Practice Location

Address: 1675 N FREEDOM BLVD
City: Provo
State: Utah
ZIP Code: 84604-2540
Phone: (888) 881-7854

Authorized Official

Name: JEROME TANNENBAUM, MD
Title: CEO AND CHAIRMAN OF THE BOARD
Phone: (615) 467-0140

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Clinic/Center - End-Stage Renal Disease (ESRD) Treatment — End-Stage Renal Disease (ESRD) Treatment	261QE0700X	Primary

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