Provider Demographics
NPI:1710468384
Name:SKULL VALLEY HEALTH CLINIC
Entity Type:Organization
Organization Name:SKULL VALLEY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-631-8362
Mailing Address - Street 1:1929 AARON DR STE I
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-8112
Mailing Address - Country:US
Mailing Address - Phone:801-631-8362
Mailing Address - Fax:
Practice Address - Street 1:1929 AARON DR STE I
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-8112
Practice Address - Country:US
Practice Address - Phone:801-631-8362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center