Healthcare Provider Details

I. General information

NPI: 1164857843
Provider Name (Legal Business Name): THE COMMUNITY HEALTH CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 E 400 S # C
SPRINGVILLE UT
84663-1958
US

IV. Provider business mailing address

382 E 400 S # C
SPRINGVILLE UT
84663-1958
US

V. Phone/Fax

Practice location:
  • Phone: 801-380-3247
  • Fax:
Mailing address:
  • Phone: 801-380-3247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number6088135-3501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: TARA TULLEY
Title or Position: MEMBER, PROGRAM DIRECTOR
Credential: LCSW, LDEM
Phone: 801-380-3247