Basic Information
| Provider Information | |||||||||
| NPI: | 1114203668 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OGDEN CLINIC SPECIALTY SERVICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OGDEN CLINIC PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5546 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802175546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014753481 | ||||||||
| FaxNumber: | 8014753494 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 HARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844034303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014753000 | ||||||||
| FaxNumber: | 8014753494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2011 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | TINGEY | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BOARD PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8014753481 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OGDEN CLINIC PC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5776572-1206 | UT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.