Basic Information
| Provider Information | |||||||||
| NPI: | 1104356013 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TANNER MEMORIAL CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TANNER CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 337 | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840410337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017734840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5296 S COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841074767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017734840 | ||||||||
| FaxNumber: | 8015258151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 01/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | SPAINHOWER | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS SERVICES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8015258726 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
No ID Information.