Healthcare Provider Details

I. General information

NPI: 1750299855
Provider Name (Legal Business Name): PORT FAMILY MEDICAL CLINIC & AESTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 S OLIVE PL
LEHI UT
84043-6605
US

IV. Provider business mailing address

529 S OLIVE PL
LEHI UT
84043-6605
US

V. Phone/Fax

Practice location:
  • Phone: 801-837-7356
  • Fax:
Mailing address:
  • Phone: 801-837-7356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CASSIE PORT
Title or Position: OWNER
Credential: FNP-C
Phone: 801-837-7356