Provider Demographics
NPI:1629807086
Name:ATLAS MEDICAL ACO LLC
Entity type:Organization
Organization Name:ATLAS MEDICAL ACO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-514-5646
Mailing Address - Street 1:PO BOX 4682
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84323-4682
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3831 E BLUE LUPINE DR STE C
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8461
Practice Address - Country:US
Practice Address - Phone:907-521-2368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLAS MEDICAL ACO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-01
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center