MEDICARE: ENTERPRISE VALLEY MEDICAL CLINIC, INC.

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	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659457786
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENTERPRISE VALLEY MEDICAL CLINIC, INC.

Provider Business Mailing Address
First Line	:	PO BOX 370
Second Line	:
City	:	ENTERPRISE
State	:	UT
Zip	:	84725-0370
Country	:	US
Telephone Number	:	435-878-2281
Fax Number	:	435-878-2434

Provider Business Practice Location Address
First Line	:	223 SOUTH 200 EAST
Second Line	:
City	:	ENTERPRISE
State	:	UT
Zip	:	84725-0370
Country	:	US
Telephone Number	:	435-878-2281
Fax Number	:	435-878-2434

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. C.J. HANSEN
Credential	:
Telephone Number	:	435-878-2281

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	08/22/2020

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