Provider Demographics
NPI:1225658800
Name:PROVIDER SERVICES NETWORK, INC.
Entity Type:Organization
Organization Name:PROVIDER SERVICES NETWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:EWING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-845-2222
Mailing Address - Street 1:5513 W 11000 N # 535
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-8012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:765 E 340 S STE 206
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-3310
Practice Address - Country:US
Practice Address - Phone:801-893-1130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10995695-0142OtherSTATE OF UTAH