Basic Information
| Provider Information | |||||||||
| NPI: | 1669422101 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IHC HEALTH SERVICES, INC | ||||||||
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| OtherOrganizationName: | UTAH VALLEY REGIONAL MEDICAL CENTER PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1034 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577475 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | SMOOT | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8013577257 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | 2006HOSP210 | UT | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator | 261QM1300X | 2006HOSP210 | UT | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.