Provider Demographics
NPI:1851690572
Name:ADVANCED CLINICAL SERVICES LLC
Entity Type:Organization
Organization Name:ADVANCED CLINICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:H
Authorized Official - Last Name:ABEGGLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-705-4311
Mailing Address - Street 1:471 E KAYS CIR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-2162
Mailing Address - Country:US
Mailing Address - Phone:435-705-4311
Mailing Address - Fax:435-213-4186
Practice Address - Street 1:471 E KAYS CIR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-2162
Practice Address - Country:US
Practice Address - Phone:435-705-4311
Practice Address - Fax:435-213-4186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4810573-4405261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP76453Medicare UPIN
UT1104909878Medicare PIN