Provider Demographics
NPI:1982669982
Name:HEALTH CLINICS OF UTAH
Entity Type:Organization
Organization Name:HEALTH CLINICS OF UTAH
Other - Org Name:STATE OF UTAH
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH PROGRAM REPRESENTATIVE-BILLE
Authorized Official - Prefix:MISS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KEYES
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:801-626-3353
Mailing Address - Street 1:150 E CENTER ST.
Mailing Address - Street 2:#1100
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606
Mailing Address - Country:US
Mailing Address - Phone:801-374-7011
Mailing Address - Fax:801-374-7009
Practice Address - Street 1:150 E. CENTER ST.
Practice Address - Street 2:#1100
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606
Practice Address - Country:US
Practice Address - Phone:801-374-7011
Practice Address - Fax:801-374-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1610961205261QP0905X
UT105991-1206261QP0905X
UT285456-4405261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05664Medicaid
UT05665Medicaid
UT535501136001Medicaid
UT000055211Medicare PIN
UTS48215Medicare UPIN
UT05665Medicaid
UT535501136001Medicaid
UTD5023Medicare UPIN
UTD20267Medicare UPIN