Provider Demographics
NPI:1255568564
Name:ASHLEY VALLEY PHYSICIAN PRACTICE LLC
Entity type:Organization
Organization Name:ASHLEY VALLEY PHYSICIAN PRACTICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7000
Mailing Address - Fax:
Practice Address - Street 1:175 N 100 W
Practice Address - Street 2:SUITE 204
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2049
Practice Address - Country:US
Practice Address - Phone:435-789-1522
Practice Address - Fax:435-789-1524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-12
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6150961-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1740245604Medicaid
UT6017780001Medicare NSC
UT000006953Medicare PIN