Provider Demographics
NPI:1184873960
Name:PHYSICIANS ADVANCED INTEGRATED NETWORK, LLC
Entity type:Organization
Organization Name:PHYSICIANS ADVANCED INTEGRATED NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-955-1555
Mailing Address - Street 1:3536 S 5600 W
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2788
Mailing Address - Country:US
Mailing Address - Phone:801-955-1555
Mailing Address - Fax:801-955-1552
Practice Address - Street 1:3536 S 5600 W
Practice Address - Street 2:SUITE 3
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2788
Practice Address - Country:US
Practice Address - Phone:801-955-1555
Practice Address - Fax:801-955-1552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114566-1202261QA1903X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical