Provider Demographics
NPI:1225193584
Name:HEALTH CLINICS OF UTAH
Entity Type:Organization
Organization Name:HEALTH CLINICS OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RETT
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-626-3670
Mailing Address - Street 1:2540 WASHINGTON BLVD
Mailing Address - Street 2:#122
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-3122
Mailing Address - Country:US
Mailing Address - Phone:801-626-3670
Mailing Address - Fax:801-626-3646
Practice Address - Street 1:2540 WASHINGTON BLVD
Practice Address - Street 2:#122
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3122
Practice Address - Country:US
Practice Address - Phone:801-626-3670
Practice Address - Fax:801-626-3646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3762451206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1225193584Medicaid
UT000055114Medicare UPIN