Provider Demographics
NPI:1487197653
Name:UTAH DEPARTMENT OF HEALTH - HEALTH CLINICS OF UTAH
Entity Type:Organization
Organization Name:UTAH DEPARTMENT OF HEALTH - HEALTH CLINICS OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FITISEMANU
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:801-499-7544
Mailing Address - Street 1:2540 WASHINGTON BLVD
Mailing Address - Street 2:SUITE 122
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-3122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2540 WASHINGTON BLVD
Practice Address - Street 2:SUITE 122
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3122
Practice Address - Country:US
Practice Address - Phone:801-395-6401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health