=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588814479
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CLINIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2008
-----------------------------------------------------
Last Update Date | 12/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 E MAIN ST
-----------------------------------------------------
City | LEHI
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84043-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-768-1699
-----------------------------------------------------
Fax | 801-768-4526
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 226 N 1100 E STE A
-----------------------------------------------------
City | AMERICAN FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84003-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-855-3843
-----------------------------------------------------
Fax | 801-855-3854
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. LARRY J PHILLIPS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-855-3844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------