Basic Information
| Provider Information | |||||||||
| NPI: | 1063536381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IHC HEALTH SERVICES INC | ||||||||
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| OtherOrganizationName: | PRIMARY CHILDREN'S HOSPITAL CHILD PSYCHOLOGY & PSYCHIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014421400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5770 S 1500 W | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841235216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013137770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | GLICKMAN | ||||||||
| AuthorizedOfficialFirstName: | SETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERMOUNTAIN MED GROUP PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8014425722 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.