Basic Information
| Provider Information | |||||||||
| NPI: | 1710496310 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDALLUS & VACHAROTHONE LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95970 | ||||||||
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| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840950970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008779236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 721 1ST AVE S UNIT A | ||||||||
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| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776339110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2017 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | VACHAROTHONE | ||||||||
| AuthorizedOfficialFirstName: | RACHOT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8012601919 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 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 | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.