Basic Information
Provider Information | |||||||||
NPI: | 1891813960 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL UTAH CLINIC, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | REVERE HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1055 N 500 W | ||||||||
Address2: | ATTN: CREDENTIALING | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846043305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013548225 | ||||||||
FaxNumber: | 8014180941 | ||||||||
Practice Location | |||||||||
Address1: | 1184 E 80 N | ||||||||
Address2: |   | ||||||||
City: | AMERICAN FORK | ||||||||
State: | UT | ||||||||
PostalCode: | 840032906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8017633885 | ||||||||
FaxNumber: | 8017633887 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2007 | ||||||||
LastUpdateDate: | 03/07/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARSTON | ||||||||
AuthorizedOfficialFirstName: | JED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED CARE | ||||||||
AuthorizedOfficialTelephone: | 8018125012 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |   | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.