Provider Demographics
NPI:1427580448
Name:ACQUA MEDICAL LLC
Entity Type:Organization
Organization Name:ACQUA MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-654-3700
Mailing Address - Street 1:1031 S DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N JOHNSON MILL RD
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:UT
Practice Address - Zip Code:84049-6764
Practice Address - Country:US
Practice Address - Phone:844-654-3700
Practice Address - Fax:801-926-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT293281-1205207QA0401X
2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========OtherEIN