1144345737 NPI number — SOUTHWEST CHILDREN'S CLINIC

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 1144345737 NPI number — SOUTHWEST CHILDREN'S CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST CHILDREN'S CLINIC
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:
Provider Other Organization Name Type Code:
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:
1144345737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8822 REDWOOD RD STE C211
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84088-9336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-563-1975
Provider Business Mailing Address Fax Number:
801-563-1984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8822 SO REDWOOD RD
Provider Second Line Business Practice Location Address:
C211
Provider Business Practice Location Address City Name:
WEST JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84088-8811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-563-1975
Provider Business Practice Location Address Fax Number:
801-563-1984
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
JILL
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
801-593-1975

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  319791-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D1713 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: D3859 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: D5092 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07027 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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