1750633558 NPI number — CENTRAL UTAH FOOT CLINIC, LLC

Table of content: (NPI 1750633558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750633558 NPI number — CENTRAL UTAH FOOT CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL UTAH FOOT CLINIC, LLC
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:
1750633558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 N 1220 E
Provider Second Line Business Mailing Address:
STE 12
Provider Business Mailing Address City Name:
AMERICAN FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84003-2089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-756-4200
Provider Business Mailing Address Fax Number:
801-756-8252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
76 E COMMERCE DR
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
SARATOGA SPRINGS
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84045-4022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-900-1130
Provider Business Practice Location Address Fax Number:
801-756-8252
Provider Enumeration Date:
10/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SUMMERS
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
801-756-4200

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  102652-0501 , 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: 1881729507 . This is a "NPI" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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