Healthcare Provider Details

I. General information

NPI: 1144439068
Provider Name (Legal Business Name): CENTRAL UTAH CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 E 50 S
AMERICAN FORK UT
84003-0000
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 801-429-8000
  • Fax: 801-429-8150
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 MANAGED CARE
Credential:
Phone: 801-812-5012