Provider Demographics
NPI:1982777074
Name:SALT LAKE PEDIA CENTER INC
Entity Type:Organization
Organization Name:SALT LAKE PEDIA CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-595-8844
Mailing Address - Street 1:77 SOUTH 700 EAST
Mailing Address - Street 2:SUITE #270
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102
Mailing Address - Country:US
Mailing Address - Phone:801-595-8844
Mailing Address - Fax:801-595-5305
Practice Address - Street 1:77 SOUTH 700 EAST
Practice Address - Street 2:SUITE #270
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:801-595-8844
Practice Address - Fax:801-595-8844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1886171205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT470667414024Medicaid
UT470667414024Medicaid