Provider Demographics
NPI:1457697369
Name:PRIMARY CHILDRENS MEDICAL CENTER
Entity Type:Organization
Organization Name:PRIMARY CHILDRENS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUBSTANCE ABUSE COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:KUSHNER
Authorized Official - Suffix:
Authorized Official - Credentials:SUDC
Authorized Official - Phone:801-313-7858
Mailing Address - Street 1:5770 SOUTH 1500 WEST
Mailing Address - Street 2:BUILDING A
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123
Mailing Address - Country:US
Mailing Address - Phone:801-313-7800
Mailing Address - Fax:
Practice Address - Street 1:5770 SOUTH 1500 WEST
Practice Address - Street 2:BUILDING A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123
Practice Address - Country:US
Practice Address - Phone:801-313-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT27438460063245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children