MEDICARE: VIVINT MEDICAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1265942163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIVINT MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	560 S 300 E STE 275
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-3586
Country	:	US
Telephone Number	:	801-441-1002
Fax Number	:

Provider Business Practice Location Address
First Line	:	4907 NORTH 300 WEST
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-8460
Country	:	US
Telephone Number	:	801-705-8040
Fax Number	:	801-765-5740

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	DARCE LATSIS
Credential	:
Telephone Number	:	801-705-8040

Provider Enumeration Date	:	10/05/2017
Last Update Date	:	01/30/2020

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Directions to “VIVINT MEDICAL CLINIC ” Practice Location

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