Provider Demographics
NPI:1881779809
Name:ASHLEY VALLEY FAMILY PRACTICE
Entity type:Organization
Organization Name:ASHLEY VALLEY FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHURTLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-781-8899
Mailing Address - Street 1:872 W HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2416
Mailing Address - Country:US
Mailing Address - Phone:435-781-8899
Mailing Address - Fax:435-781-8898
Practice Address - Street 1:872 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2416
Practice Address - Country:US
Practice Address - Phone:435-781-8899
Practice Address - Fax:435-781-8898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
07/16/1967OtherOWNER'S BIRTHDATE