Provider Demographics
NPI:1407947005
Name:FOOTHILL CLINIC, LLC
Entity Type:Organization
Organization Name:FOOTHILL CLINIC, LLC
Other - Org Name:FOOTHILL FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:801-486-3021
Mailing Address - Street 1:2295 FOOTHILL DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-4000
Mailing Address - Country:US
Mailing Address - Phone:801-486-3021
Mailing Address - Fax:801-485-6339
Practice Address - Street 1:2295 FOOTHILL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-4000
Practice Address - Country:US
Practice Address - Phone:801-486-3021
Practice Address - Fax:801-485-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005505400Medicare PIN
UT4195970002Medicare NSC