Healthcare Provider Details

I. General information

NPI: 1417066176
Provider Name (Legal Business Name): SALT LAKE FAMILY HEALTH CNTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 E SOUTH TEMPLE 404
SALT LAKE CITY UT
84102
US

IV. Provider business mailing address

1002 E SOUTH TEMPLE 404
SALT LAKE CITY UT
84102
US

V. Phone/Fax

Practice location:
  • Phone: 801-350-4479
  • Fax: 801-350-4377
Mailing address:
  • Phone: 801-350-4479
  • Fax: 801-350-4377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27746451205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3560871205
License Number StateUT

VIII. Authorized Official

Name: DR. PAUL RICHARD SWOBODA
Title or Position: PRESIDENT
Credential: MD
Phone: 801-350-4479