Provider Demographics
NPI:1912267212
Name:IHC HEALTH SERVICES INC
Entity Type:Organization
Organization Name:IHC HEALTH SERVICES INC
Other - Org Name:PACIFIC STATES CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO INTERMOUNTAIN MEDICAL GROUP
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LECKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-442-3974
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-373-6910
Mailing Address - Fax:
Practice Address - Street 1:1401 E 2000 S
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-2072
Practice Address - Country:US
Practice Address - Phone:801-373-6910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8082012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055456Medicare UPIN