Healthcare Provider Details

I. General information

NPI: 1427580448
Provider Name (Legal Business Name): ACQUA MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N JOHNSON MILL RD
MIDWAY UT
84049-6764
US

IV. Provider business mailing address

1031 S DOUGLAS ST
SALT LAKE CITY UT
84105-1505
US

V. Phone/Fax

Practice location:
  • Phone: 844-654-3700
  • Fax: 801-926-1133
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number293281-1205
License Number StateUT

VIII. Authorized Official

Name: CLINT TOLMAN
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 844-654-3700