Provider Demographics
NPI: | 1487656781 |
---|---|
Name: | TOOELE CLINIC CORPORATION |
Entity Type: | Organization |
Organization Name: | TOOELE CLINIC CORPORATION |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | SENIOR GROUP VP |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | MICHAELE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | PORTACCI |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 615-309-3340 |
Mailing Address - Street 1: | 330 FRANKLIN RD |
Mailing Address - Street 2: | |
Mailing Address - City: | BRENTWOOD |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37027-3280 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 615-309-3338 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 330 FRANKLIN RD #135A-304 |
Practice Address - Street 2: | |
Practice Address - City: | BRENTWOOD |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37027-3280 |
Practice Address - Country: | US |
Practice Address - Phone: | 615-309-3338 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-06-01 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
UT | 87063588 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty |