Provider Demographics
NPI:1881729507
Name:CENTRAL UTAH FOOT CLINIC, LLC
Entity type:Organization
Organization Name:CENTRAL UTAH FOOT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-375-5353
Mailing Address - Street 1:150 W 800 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1624
Mailing Address - Country:US
Mailing Address - Phone:801-375-5353
Mailing Address - Fax:801-375-5395
Practice Address - Street 1:150 W 800 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1624
Practice Address - Country:US
Practice Address - Phone:801-375-5353
Practice Address - Fax:801-375-5395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT102652-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0988730001Medicare ID - Type UnspecifiedDURABLE MEDICAL