Healthcare Provider Details

I. General information

NPI: 1104124015
Provider Name (Legal Business Name): MIDTOWN COMMUNITY HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 26TH ST
OGDEN UT
84401-3105
US

IV. Provider business mailing address

2240 ADAMS AVE
OGDEN UT
84401-1511
US

V. Phone/Fax

Practice location:
  • Phone: 801-625-3700
  • Fax: 801-394-4609
Mailing address:
  • Phone: 801-393-5355
  • Fax: 801-394-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MS. SONJA LEVESQUE
Title or Position: CFO
Credential:
Phone: 801-334-1327