Provider Demographics
NPI:1669611661
Name:UTAH INJURY CLINIC, LLC
Entity type:Organization
Organization Name:UTAH INJURY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:801-747-2886
Mailing Address - Street 1:4700 S 900 E STE 41G
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4938
Mailing Address - Country:US
Mailing Address - Phone:801-376-9596
Mailing Address - Fax:801-716-3532
Practice Address - Street 1:4700 S 900 E STE 41G
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4938
Practice Address - Country:US
Practice Address - Phone:801-747-2886
Practice Address - Fax:801-716-3532
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRALINE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-13
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6715760-1202261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center