Organization
SRS-PROVO, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JEROME TANNENBAUM MD (CEO AND CHAIRMAN OF THE BOARD)
(615) 467-0140
Entity
Organization
Contact information
Practice address
1675 N FREEDOM BLVD, PROVO, UT 84604-2540
(888) 881-7854
(885) 631-0206
Mailing address
PO BOX 198813, NASHVILLE, TN 37219-8813
(615) 988-1060
(855) 631-0206
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
—
—
Other
Enumeration date
05/20/2021
Last updated
05/21/2021
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