Healthcare Provider Details

I. General information

NPI: 1245267467
Provider Name (Legal Business Name): HTI PHYSICAN SERVICES OF UTAH,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 5TH STREET SUITE A
WILDER ID
83676-0037
US

IV. Provider business mailing address

1717 ARLINGTON AVE
CALDWELL ID
83605-4802
US

V. Phone/Fax

Practice location:
  • Phone: 208-482-7430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JULIE TAYLOR
Title or Position: CEO
Credential:
Phone: 208-455-3718