Provider Demographics
NPI:1679956445
Name:PINE TOP MEDICAL P.C.
Entity Type:Organization
Organization Name:PINE TOP MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:801-309-5156
Mailing Address - Street 1:284 N HOSPITAL DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-4233
Mailing Address - Country:US
Mailing Address - Phone:435-637-5690
Mailing Address - Fax:435-637-9809
Practice Address - Street 1:284 N HOSPITAL DR
Practice Address - Street 2:SUITE 2
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-4233
Practice Address - Country:US
Practice Address - Phone:435-637-5690
Practice Address - Fax:435-637-9809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT93369771204261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center