Provider Demographics
NPI:1114203668
Name:OGDEN CLINIC SPECIALTY SERVICES LLC
Entity Type:Organization
Organization Name:OGDEN CLINIC SPECIALTY SERVICES LLC
Other - Org Name:OGDEN CLINIC PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TINGEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-475-3481
Mailing Address - Street 1:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3481
Mailing Address - Fax:801-475-3494
Practice Address - Street 1:4650 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4303
Practice Address - Country:US
Practice Address - Phone:801-475-3000
Practice Address - Fax:801-475-3494
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OGDEN CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-28
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
UT5776572-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty