Provider Demographics
NPI:1013212802
Name:YOUR HOME CLINIC COMPANY
Entity Type:Organization
Organization Name:YOUR HOME CLINIC COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:NEWBY
Authorized Official - Suffix:
Authorized Official - Credentials:GNP
Authorized Official - Phone:801-641-9261
Mailing Address - Street 1:1032 LEARNED AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3302
Mailing Address - Country:US
Mailing Address - Phone:801-641-9261
Mailing Address - Fax:801-521-4496
Practice Address - Street 1:1032 LEARNED AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-3302
Practice Address - Country:US
Practice Address - Phone:801-641-9261
Practice Address - Fax:801-521-4496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT308579-4405363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty