Provider Demographics
NPI:1033412481
Name:VALLEY FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:VALLEY FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:FORBES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-843-1225
Mailing Address - Street 1:2376 N 400 E STE 102
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3413
Mailing Address - Country:US
Mailing Address - Phone:435-843-1225
Mailing Address - Fax:435-843-1228
Practice Address - Street 1:2376 N 400 E STE 102
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3413
Practice Address - Country:US
Practice Address - Phone:435-843-1225
Practice Address - Fax:435-843-1228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT346411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT308723752008Medicaid
UT000011923Medicare PIN