=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407294614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEEM FAMILY CLINIC, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2013
-----------------------------------------------------
Last Update Date | 06/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 EAST 800 NORTH
-----------------------------------------------------
City | DUCHESNE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84066-0238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-738-8336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 990 CLUB HOUSE DR
-----------------------------------------------------
City | ROOSEVELT
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84066-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-722-4705
-----------------------------------------------------
Fax | 435-738-8338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD DIRECTOR
-----------------------------------------------------
Name | MS. LORI TEEM
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 435-722-4705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 215999-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------