Organization
BLUE ROCK NEUROLOGICAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WENDELL GIBBY MD (MANAGER/OWNER)
(801) 229-1014
Entity
Organization
Contact information
Practice address
3152 N UNIVERSITY AVE STE 220, PROVO, UT 84604-4746
(801) 229-1014
(801) 229-1067
Mailing address
3152 N UNIVERSITY AVE STE 220, PROVO, UT 84604-4746
(801) 229-1014
(801) 229-1067
Taxonomy
Speciality
Code
Description
License number
State
207QA0401X
Addiction Medicine (Family Medicine) Physician
—
UT
2084N0400X
Neurology Physician
Primary
—
UT
208VP0014X
Interventional Pain Medicine Physician
—
UT
363AM0700X
Medical Physician Assistant
—
UT
363LF0000X
Family Nurse Practitioner
—
UT
Other
Enumeration date
12/02/2015
Last updated
12/02/2015
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