Provider Demographics
NPI:1326169632
Name:WEST VALLEY FAMILY AND PREVENTIVE MEDICINE
Entity Type:Organization
Organization Name:WEST VALLEY FAMILY AND PREVENTIVE MEDICINE
Other - Org Name:WEST VALLEY FAMILY AND PREVENTIVE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:JANAE
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-964-8726
Mailing Address - Street 1:3336 PIONEER PKWY
Mailing Address - Street 2:#302
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2000
Mailing Address - Country:US
Mailing Address - Phone:801-964-8726
Mailing Address - Fax:801-968-9836
Practice Address - Street 1:4100 SOUTH 1778 WEST
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119
Practice Address - Country:US
Practice Address - Phone:801-964-8726
Practice Address - Fax:801-968-9836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT480025031002Medicaid
UT480025031002Medicaid
UT000057417Medicare ID - Type UnspecifiedGROUP MCR NUMBER