Provider Demographics
NPI:1396369435
Name:ADVANCED INTEGRATED MEDICAL LLC
Entity Type:Organization
Organization Name:ADVANCED INTEGRATED MEDICAL LLC
Other - Org Name:ADVANCED INTEGRATED MEDICAL OF CACHE VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-764-1775
Mailing Address - Street 1:1635 N 200 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1913
Mailing Address - Country:US
Mailing Address - Phone:435-932-6138
Mailing Address - Fax:435-213-9325
Practice Address - Street 1:1635 N 200 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1913
Practice Address - Country:US
Practice Address - Phone:435-932-6138
Practice Address - Fax:435-213-9325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-04
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1962456681OtherOTHER INSURERS