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General NPI Number Information
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NPI Number | 1255691929
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Entity Type | Organization
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Legal Business Name | SOUTH PAYSON MEDICAL CLINIC
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Dates
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Enumeration Date | 05/29/2012
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Last Update Date | 06/22/2012
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Provider Practice Location Address
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Address Line | 828 S 1040 W
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City | PAYSON
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State | UT
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Zip | 84651-4614
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Country | US
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Telephone | 940-634-1977
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Fax |
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Provider Business Mailing Address
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Address Line | 828 S 1040 W
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City | PAYSON
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State | UT
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Zip | 84651-4614
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Country | US
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Telephone | 940-634-1977
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. BRENT MEREDITH
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Credential | PA-C
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Telephone | 940-634-1977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 2785828-1206
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License Number State | UT
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