Provider Demographics
NPI:1710339445
Name:SALT LAKE VALLEY CLINIC LLC
Entity Type:Organization
Organization Name:SALT LAKE VALLEY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-593-6777
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-0640
Mailing Address - Country:US
Mailing Address - Phone:801-593-6777
Mailing Address - Fax:
Practice Address - Street 1:4141 S HIGHLAND DR STE 208
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84124-2656
Practice Address - Country:US
Practice Address - Phone:801-593-6777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center