Provider Demographics
NPI:1518247709
Name:ASHLEY VALLEY PHYSICIAN PRACTICE, LLC
Entity Type:Organization
Organization Name:ASHLEY VALLEY PHYSICIAN PRACTICE, LLC
Other - Org Name:ROOSEVELT COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:409 S 200 E
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-3314
Mailing Address - Country:US
Mailing Address - Phone:435-725-3327
Mailing Address - Fax:435-725-3331
Practice Address - Street 1:409 S 200 E
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-3314
Practice Address - Country:US
Practice Address - Phone:435-725-3327
Practice Address - Fax:435-725-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty