Healthcare Provider Details

I. General information

NPI: 1982958641
Provider Name (Legal Business Name): INTERMOUNTAIN SENIOR CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 S 250E SUITE 210
MURRAY UT
84107
US

IV. Provider business mailing address

5770 S 250E SUITE 210
MURRAY UT
84107
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-4544
  • Fax: 801-314-4565
Mailing address:
  • Phone: 801-314-4544
  • Fax: 801-314-4565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6262134-3501
License Number StateUT

VIII. Authorized Official

Name: KAY SUE SIMONS
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: MSW, LCSW
Phone: 801-314-4550