Provider Demographics
NPI:1770903700
Name:CALTONHARRISON CLINIC
Entity type:Organization
Organization Name:CALTONHARRISON CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING LEAD
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWNELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-387-2750
Mailing Address - Street 1:4403 HARRISON BLVD
Mailing Address - Street 2:SUITE 2400
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3271
Mailing Address - Country:US
Mailing Address - Phone:801-387-2750
Mailing Address - Fax:801-387-2755
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:SUITE 2400
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-2750
Practice Address - Fax:801-387-2755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1720123383Medicare UPIN