Provider Demographics
NPI:1881945608
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:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-756-4200
Mailing Address - Street 1:120 N 1220 E
Mailing Address - Street 2:STE 12
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2089
Mailing Address - Country:US
Mailing Address - Phone:801-756-4200
Mailing Address - Fax:801-756-8252
Practice Address - Street 1:120 N 1220 E
Practice Address - Street 2:STE 12
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2089
Practice Address - Country:US
Practice Address - Phone:801-756-4200
Practice Address - Fax:801-756-8252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT102652-0501213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1881729507OtherNPI