Provider Demographics
NPI:1255602223
Name:THE CLINIC, PC
Entity type:Organization
Organization Name:THE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-855-3844
Mailing Address - Street 1:226 N 1100 E STE A
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2054
Mailing Address - Country:US
Mailing Address - Phone:801-855-3843
Mailing Address - Fax:801-855-3854
Practice Address - Street 1:76 E COMMERCE DR STE 204
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-4024
Practice Address - Country:US
Practice Address - Phone:801-766-8427
Practice Address - Fax:801-766-5657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055003Medicare PIN