Provider Demographics
NPI:1043903024
Name:FAMILY TREE PREVENTATIVE MEDICINE LLC
Entity Type:Organization
Organization Name:FAMILY TREE PREVENTATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:VIGIL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:801-698-2144
Mailing Address - Street 1:5185 S 2275 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-3442
Mailing Address - Country:US
Mailing Address - Phone:801-698-2144
Mailing Address - Fax:
Practice Address - Street 1:5185 S 2275 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-3442
Practice Address - Country:US
Practice Address - Phone:801-698-2144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-26
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care