Provider Demographics
NPI:1104208412
Name:FJM OGDEN
Entity Type:Organization
Organization Name:FJM OGDEN
Other - Org Name:ONSITE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LATSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-441-1002
Mailing Address - Street 1:560 S 300 E STE 275
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3586
Mailing Address - Country:US
Mailing Address - Phone:801-441-1002
Mailing Address - Fax:
Practice Address - Street 1:1104 COUNTRY HILLS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2400
Practice Address - Country:US
Practice Address - Phone:801-624-1633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT94364441725261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care