1508896838 NPI number — CENTRAL UTAH CLINIC, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508896838 NPI number — CENTRAL UTAH CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL UTAH CLINIC, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
REVERE HEALTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508896838
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1055 N 500 W
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-3305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-354-8225
Provider Business Mailing Address Fax Number:
801-418-0941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
97 S PROFESSIONAL WAY
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PAYSON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84651-1614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-465-4896
Provider Business Practice Location Address Fax Number:
801-465-4107
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARSTON
Authorized Official First Name:
JED
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF MANAGED CARE
Authorized Official Telephone Number:
801-812-5012

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 870609595000 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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