Provider Demographics
NPI:1215001037
Name:KANE COUNTY HUMAN RESOURCE SPECIAL SERVICE DISTRICT
Entity Type:Organization
Organization Name:KANE COUNTY HUMAN RESOURCE SPECIAL SERVICE DISTRICT
Other - Org Name:KANE COUNTY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-644-5811
Mailing Address - Street 1:355 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KANAB
Mailing Address - State:UT
Mailing Address - Zip Code:84741-3260
Mailing Address - Country:US
Mailing Address - Phone:435-644-4100
Mailing Address - Fax:435-644-4197
Practice Address - Street 1:355 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741-3260
Practice Address - Country:US
Practice Address - Phone:435-644-4100
Practice Address - Fax:435-644-4197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
87600030002001OtherBCBS
87600030002001OtherBCBS