Provider Demographics
NPI:1326745787
Name:RIVENDELL CLINIC LLC
Entity Type:Organization
Organization Name:RIVENDELL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:INGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:385-985-8423
Mailing Address - Street 1:826 EXPRESSWAY LN UNIT 746
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1300
Mailing Address - Country:US
Mailing Address - Phone:385-446-5010
Mailing Address - Fax:
Practice Address - Street 1:1381 ALPINE LOOP
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5300
Practice Address - Country:US
Practice Address - Phone:385-446-5010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center