Healthcare Provider Details

I. General information

NPI: 1083158257
Provider Name (Legal Business Name): UNIVERSITY OF UTAH ADULT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR CLINIC # 7
SALT LAKE CITY UT
84132-1261
US

IV. Provider business mailing address

PO BOX 841450
LOS ANGELES CA
90084-1450
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2016
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD H CLARK
Title or Position: DEPARTMENT CHAIR
Credential:
Phone: 801-587-6636