Provider Demographics
NPI:1538867999
Name:CENTRAL UTAH CLINIC, P.C.
Entity type:Organization
Organization Name:CENTRAL UTAH CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:JED
Authorized Official - Middle Name:BRADLEY
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:ATT CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1022 N REDWOOD RD STE B
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-5387
Practice Address - Country:US
Practice Address - Phone:801-373-7350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty