Provider Demographics
NPI:1417066176
Name:SALT LAKE FAMILY HEALTH CNTR
Entity Type:Organization
Organization Name:SALT LAKE FAMILY HEALTH CNTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:SWOBODA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-350-4479
Mailing Address - Street 1:1002 E SOUTH TEMPLE 404
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102
Mailing Address - Country:US
Mailing Address - Phone:801-350-4479
Mailing Address - Fax:801-350-4377
Practice Address - Street 1:1002 E SOUTH TEMPLE 404
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:801-350-4479
Practice Address - Fax:801-350-4377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3560871205207Q00000X
UT27746451205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT496801378020Medicaid
UT496801378020Medicaid