Provider Demographics
NPI:1508896838
Name:CENTRAL UTAH CLINIC, P.C.
Entity Type:Organization
Organization Name:CENTRAL UTAH CLINIC, P.C.
Other - Org Name:REVERE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:JED
Authorized Official - Middle Name:
Authorized Official - Last Name:HARSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-812-5012
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:97 S PROFESSIONAL WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1614
Practice Address - Country:US
Practice Address - Phone:801-465-4896
Practice Address - Fax:801-465-4107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870609595000Medicaid
UT0055601Medicare ID - Type Unspecified