Provider Demographics
NPI:1386863108
Name:ADVANCED HEALTH CLINIC
Entity Type:Organization
Organization Name:ADVANCED HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:801-447-8680
Mailing Address - Street 1:630 SHEPARD LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-3934
Mailing Address - Country:US
Mailing Address - Phone:801-447-8680
Mailing Address - Fax:801-447-4211
Practice Address - Street 1:630 SHEPARD LN
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-3934
Practice Address - Country:US
Practice Address - Phone:801-447-8680
Practice Address - Fax:801-447-4211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty