Provider Demographics
NPI:1851142285
Name:CENTRAL UTAH CLINIC PC
Entity Type:Organization
Organization Name:CENTRAL UTAH CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JED
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:HARSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-812-5012
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATT CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:972 N 600 E
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1306
Practice Address - Country:US
Practice Address - Phone:801-373-7350
Practice Address - Fax:801-812-5401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty