Basic Information
| Provider Information | |||||||||
| NPI: | 1265674246 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IHC HEALTH SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4646 LAKE PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841208212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014428468 | ||||||||
| FaxNumber: | 8014420066 | ||||||||
| Practice Location | |||||||||
| Address1: | 4646 LAKE PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841208212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014421466 | ||||||||
| FaxNumber: | 8014420066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2009 | ||||||||
| LastUpdateDate: | 04/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | PAYNE | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICARE ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8014428468 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.