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General NPI Number Information
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NPI Number | 1750728176
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Entity Type | Organization
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Legal Business Name | MAIN STREET CLINIC LLC
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Dates
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Enumeration Date | 05/24/2013
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Last Update Date | 05/24/2013
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Provider Practice Location Address
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Address Line | 46 N MAIN ST
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City | MANTI
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State | UT
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Zip | 84642-1254
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Country | US
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Telephone | 435-835-6000
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Fax | 435-835-6004
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Provider Business Mailing Address
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Address Line | 46 N MAIN ST
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City | MANTI
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State | UT
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Zip | 84642-1254
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Country | US
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Telephone | 435-835-6000
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. LAUREN LINN MILLER
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Credential | FNP-BC
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Telephone | 435-835-6000
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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 | 2158984405
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License Number State | UT
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