=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427580448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACQUA MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2017
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 N JOHNSON MILL RD
-----------------------------------------------------
City | MIDWAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84049-6764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-654-3700
-----------------------------------------------------
Fax | 801-926-1133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1031 S DOUGLAS ST
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84105-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE DIRECTOR
-----------------------------------------------------
Name | CLINT TOLMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 844-654-3700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 293281-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------