Provider Demographics
NPI:1740461219
Name:MA BO INC
Entity type:Organization
Organization Name:MA BO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CAITLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CACCIATORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-485-5055
Mailing Address - Street 1:466 E 500 S STE 200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3350
Mailing Address - Country:US
Mailing Address - Phone:801-485-5055
Mailing Address - Fax:801-467-3296
Practice Address - Street 1:466 E 500 S STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3350
Practice Address - Country:US
Practice Address - Phone:801-485-5055
Practice Address - Fax:801-467-3296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057838OtherPTAN