Provider Demographics
NPI:1255692075
Name:SUPERIOR HEALTHCARE OF SPANISH FORK
Entity Type:Organization
Organization Name:SUPERIOR HEALTHCARE OF SPANISH FORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:NEPHI
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-798-2515
Mailing Address - Street 1:750 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1147
Mailing Address - Country:US
Mailing Address - Phone:801-798-2515
Mailing Address - Fax:801-798-2510
Practice Address - Street 1:750 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1147
Practice Address - Country:US
Practice Address - Phone:801-798-2515
Practice Address - Fax:801-798-2510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5129809-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty