Healthcare Provider Details

I. General information

NPI: 1669930475
Provider Name (Legal Business Name): CENTRAL UTAH CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 FALCON RIDGE PKWY STE 400A
MESQUITE NV
89027-8881
US

IV. Provider business mailing address

1055 N 500 W ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-377-5757
  • Fax: 801-418-0941
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JED BRADLEY HARSTON
Title or Position: DIRECTOR OF PAYER RELATIONS
Credential:
Phone: 801-812-5012