Provider Demographics
NPI:1578100186
Name:124 SOUTH FAIRFIELD LLC
Entity Type:Organization
Organization Name:124 SOUTH FAIRFIELD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-791-2202
Mailing Address - Street 1:124 S FAIRFIELD RD STE B
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-7106
Mailing Address - Country:US
Mailing Address - Phone:801-719-2316
Mailing Address - Fax:801-336-4873
Practice Address - Street 1:124 S FAIRFIELD RD STE B
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7106
Practice Address - Country:US
Practice Address - Phone:801-719-2316
Practice Address - Fax:801-336-4873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-02
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center