Healthcare Provider Details

I. General information

NPI: 1184766826
Provider Name (Legal Business Name): ADVANCED THERAPY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 E 530 N REAR
AMERICAN FORK UT
84003-1955
US

IV. Provider business mailing address

875 E 530 N REAR
AMERICAN FORK UT
84003-1965
US

V. Phone/Fax

Practice location:
  • Phone: 801-427-8887
  • Fax: 801-756-3444
Mailing address:
  • Phone: 801-427-8887
  • Fax: 801-756-3444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6094910-0160
License Number StateUT

VIII. Authorized Official

Name: MRS. KAY MARIE SMITH
Title or Position: PARTNER
Credential: N.C.T.M.B., L.L.C.C
Phone: 801-380-8480