# LEGACY DERMATOLOGY

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1376944942
- **Authorized official:** DR. JARED REX HEATON D.O. (PHYSICIAN)
- **Authorized official phone:** (435) 770-9247

## Contact information

- **Practice address:** 320 W 500 S, SUITE 210, BOUNTIFUL, UT 84010-7218
- **Practice address phone:** (385) 312-0650
- **Practice address fax:** (385) 743-3333
- **Mailing address:** 1535 LAKEVIEW DR, BOUNTIFUL, UT 84010-1561
- **Mailing address phone:** (435) 770-9247

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | 9017921-1204 | UT | Yes |

## Other

- **Enumeration date:** 09/14/2014
- **Last updated:** 09/14/2014