Provider Demographics
NPI:1164519856
Name:ADVANCE MEDICAL SERVICES, INC
Entity Type:Organization
Organization Name:ADVANCE MEDICAL SERVICES, INC
Other - Org Name:PETERSEN MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-373-1010
Mailing Address - Street 1:1268 S 1380 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-4911
Mailing Address - Country:US
Mailing Address - Phone:801-373-1010
Mailing Address - Fax:801-373-2217
Practice Address - Street 1:1268 S 1380 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-4911
Practice Address - Country:US
Practice Address - Phone:801-374-8101
Practice Address - Fax:801-374-8121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BC3200X
UT6088482-1714332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========015Medicaid
UT=========015Medicaid