Provider Demographics
NPI:1033674916
Name:ADVANCED INTEGRATED MEDICAL CENTER
Entity Type:Organization
Organization Name:ADVANCED INTEGRATED MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-764-1775
Mailing Address - Street 1:1742 N 500 W APT 102
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2875
Mailing Address - Country:US
Mailing Address - Phone:435-764-1775
Mailing Address - Fax:
Practice Address - Street 1:1395 NW MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-3936
Practice Address - Country:US
Practice Address - Phone:208-785-0270
Practice Address - Fax:208-785-0683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-05
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1962456681OtherPERSONAL NPI