Basic Information
| Provider Information | |||||||||
| NPI: | 1316421761 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH CENTERS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2621 S 3270 W | ||||||||
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| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841191119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3852612614 | ||||||||
| FaxNumber: | 8017460420 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 S 200 E STE #B | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015398617 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2018 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | PEARCE | ||||||||
| AuthorizedOfficialFirstName: | DEXTER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3852612614 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH CENTERS, INC. | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.