Basic Information
| Provider Information | |||||||||
| NPI: | 1760773923 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WORK CARE-SOUTH SIDE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 271395 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841260692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017481600 | ||||||||
| FaxNumber: | 8017481601 | ||||||||
| Practice Location | |||||||||
| Address1: | 12422 S 450 E | ||||||||
| Address2: | |||||||||
| City: | DRAPER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840208050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017481600 | ||||||||
| FaxNumber: | 8017481601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2011 | ||||||||
| LastUpdateDate: | 04/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8019751600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | UT | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.