MEDICARE: SAGE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	70619161204	UT

General Provider Information

NPI Number	:	1285003335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGE CLINIC

Provider Business Mailing Address
First Line	:	560 S 300 E STE 275
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-3586
Country	:	US
Telephone Number	:	801-441-1002
Fax Number	:

Provider Business Practice Location Address
First Line	:	7285 WEST 21200 NORTH
Second Line	:
City	:	PLYMOUTH
State	:	UT
Zip	:	84330
Country	:	US
Telephone Number	:	435-458-9205
Fax Number	:	435-458-2361

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	DARCE LATSIS
Credential	:
Telephone Number	:	801-441-1002

Provider Enumeration Date	:	09/18/2015
Last Update Date	:	01/30/2020

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Directions to “SAGE CLINIC ” Practice Location

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