Healthcare Provider Details

I. General information

NPI: 1548969306
Provider Name (Legal Business Name): MEDICALLY DIRECTED CARE CLINIC SALT LAKE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4465 S 900 E STE 2754
SALT LAKE CITY UT
84124-2469
US

IV. Provider business mailing address

4465 S 900 E STE 2754
SALT LAKE CITY UT
84124-2469
US

V. Phone/Fax

Practice location:
  • Phone: 435-300-0472
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AJ YERGENSEN
Title or Position: ADMIN
Credential:
Phone: 435-986-9369