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610 S 200 E Ste #b Salt Lake City UT 84111 | |
| (801) 539-8617 | |
| (877) 497-4661 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 610 S 200 E Ste #b, Salt Lake City, Utah |
| Authorized Official Name and Position | Jennifer Thomas (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 8014126920 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1455 W 2200 S Ste 300 West Valley City UT 84119-7219 Ph: (801) 412-6920 | 610 S 200 E Ste #b Salt Lake City UT 84111 Ph: (801) 539-8617 |
| NPI Number | 1316421761 |
|---|---|
| Provider Enumeration Date | 09/21/2018 |
| Last Update Date | 10/30/2023 |
| Certification Date | 10/30/2023 |
| Medicare PECOS PAC ID | 5991698169 |
|---|---|
| Medicare Enrollment ID | O20181031000683 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1316421761 | NPI | - | NPPES |
| 1316421761 | Medicaid | UT |
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