Healthcare Provider Details

I. General information

NPI: 1245237080
Provider Name (Legal Business Name): RICHARD CLARK CLINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 MYRTLE AVENUE SUITE 204
MURRAY UT
84107-4850
US

IV. Provider business mailing address

PO BOX 71506 SUITE 204
SALT LAKE CITY UT
84171-0506
US

V. Phone/Fax

Practice location:
  • Phone: 801-288-9002
  • Fax: 801-288-8987
Mailing address:
  • Phone: 801-903-8956
  • Fax: 801-288-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number173525-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: