Basic Information
| Provider Information | |||||||||
| NPI: | 1861084949 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OGDEN CLINIC SPECIALTY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5546 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802175546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014753500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4700 HARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844034303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014753160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2021 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | MARCHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 8014753481 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OGDEN CLINIC UROLOGY PHARMACY | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 1114203668 | 05 | UT | MEDICAID |