Provider Demographics
NPI:1659457786
Name:ENTERPRISE VALLEY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:ENTERPRISE VALLEY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:C.J.
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-878-2281
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:UT
Mailing Address - Zip Code:84725-0370
Mailing Address - Country:US
Mailing Address - Phone:435-878-2281
Mailing Address - Fax:435-878-2434
Practice Address - Street 1:223 SOUTH 200 EAST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:UT
Practice Address - Zip Code:84725-0370
Practice Address - Country:US
Practice Address - Phone:435-878-2281
Practice Address - Fax:435-878-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05883Medicaid
UT461803Medicare ID - Type UnspecifiedPROVIDER NUMBER