Basic Information
| Provider Information | |||||||||
| NPI: | 1730507161 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIRECT CARE MEDICAL HOME CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7611 S JORDAN LANDING BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840845612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012601919 | ||||||||
| FaxNumber: | 8012601441 | ||||||||
| Practice Location | |||||||||
| Address1: | 7611 S JORDAN LANDING BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840845612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012601919 | ||||||||
| FaxNumber: | 8012601441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2014 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | VACHAROTHONE | ||||||||
| AuthorizedOfficialFirstName: | RACHOT | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/ URGENT CARE PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8012601919 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | UT | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.