Healthcare Provider Details

I. General information

NPI: 1053861567
Provider Name (Legal Business Name): ADVANTAGE MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 S 200 E STE 102
BRIGHAM CITY UT
84302
US

IV. Provider business mailing address

770 S 200 E STE 102
BRIGHAM CITY UT
84302
US

V. Phone/Fax

Practice location:
  • Phone: 435-723-0517
  • Fax: 435-723-0587
Mailing address:
  • Phone: 435-723-0517
  • Fax: 435-723-0587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number189510-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5118842-0160
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JEREMIAH HOOPES
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 435-723-0517