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General NPI Number Information
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NPI Number | 1023490091
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Entity Type | Organization
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Legal Business Name | CLANTON ENTERPRISES, SERIES LLC
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Dates
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Enumeration Date | 06/25/2015
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Last Update Date | 06/25/2015
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Provider Practice Location Address
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Address Line | 75 S 200 E SUITE 202
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City | PROVO
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State | UT
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Zip | 84606-3146
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Country | US
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Telephone | 801-375-2207
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Fax | 801-375-2307
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Provider Business Mailing Address
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Address Line | 75 S 200 E SUITE 202
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City | PROVO
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State | UT
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Zip | 84606-3146
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Country | US
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Telephone | 801-375-2207
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Fax | 801-375-2307
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | BARRY A CLANTON
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Credential | P.A.
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Telephone | 801-375-2207
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 7417572-1206
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License Number State | UT
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