Provider Demographics
NPI:1255858734
Name:FJM BASECAMP
Entity Type:Organization
Organization Name:FJM BASECAMP
Other - Org Name:FJM MEDICAL CLINIC-BASECAMP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LATSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-441-1002
Mailing Address - Street 1:560 S 300 E STE 275
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3586
Mailing Address - Country:US
Mailing Address - Phone:801-441-1002
Mailing Address - Fax:
Practice Address - Street 1:185 S STATE ST STE 208
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1558
Practice Address - Country:US
Practice Address - Phone:801-821-5454
Practice Address - Fax:801-821-5455
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FUTURA MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT70786441205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty