Provider Demographics
NPI:1730554734
Name:BLUE ROCK NEUROLOGICAL LLC
Entity type:Organization
Organization Name:BLUE ROCK NEUROLOGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-229-1014
Mailing Address - Street 1:3152 N UNIVERSITY AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4746
Mailing Address - Country:US
Mailing Address - Phone:801-229-1014
Mailing Address - Fax:801-229-1067
Practice Address - Street 1:3152 N UNIVERSITY AVE STE 220
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4746
Practice Address - Country:US
Practice Address - Phone:801-229-1014
Practice Address - Fax:801-229-1067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT207QA0401X, 208VP0014X, 363AM0700X, 363LF0000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty