Basic Information
| Provider Information | |||||||||
| NPI: | 1619486396 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOLINA HEALTHCARE OF UTAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885625442 | ||||||||
| FaxNumber: | 5624996191 | ||||||||
| Practice Location | |||||||||
| Address1: | 7050 S UNION PARK AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | MIDVALE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840474171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885625442 | ||||||||
| FaxNumber: | 5624996191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2017 | ||||||||
| LastUpdateDate: | 01/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | TURLEY | ||||||||
| AuthorizedOfficialFirstName: | GINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, CLINIC INFORMATICS | ||||||||
| AuthorizedOfficialTelephone: | 8885625442 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOLINA HEALTHCARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.