Provider Demographics
NPI:1801379193
Name:COUNTRY CORNER FAMILY MEDICINE
Entity Type:Organization
Organization Name:COUNTRY CORNER FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KORTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:435-749-1488
Mailing Address - Street 1:5460 W CLERNATES DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118-8526
Mailing Address - Country:US
Mailing Address - Phone:435-749-1488
Mailing Address - Fax:801-880-2859
Practice Address - Street 1:5460 W CLERNATES DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-8526
Practice Address - Country:US
Practice Address - Phone:435-749-1488
Practice Address - Fax:801-880-2859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty