Provider Demographics
NPI:1467097071
Name:CENTRIC PHYSICIANS INTERMOUNTAIN REGION, PLLC
Entity Type:Organization
Organization Name:CENTRIC PHYSICIANS INTERMOUNTAIN REGION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-267-4575
Mailing Address - Street 1:113 PLEASANT VALLEY DR STE 210
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-5683
Mailing Address - Country:US
Mailing Address - Phone:830-267-4575
Mailing Address - Fax:830-267-4575
Practice Address - Street 1:7101 N MESA STREET #365
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1603
Practice Address - Country:US
Practice Address - Phone:830-267-4575
Practice Address - Fax:830-267-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-07
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty