Provider Demographics
NPI:1144345737
Name:SOUTHWEST CHILDREN'S CLINIC
Entity type:Organization
Organization Name:SOUTHWEST CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-593-1975
Mailing Address - Street 1:8822 REDWOOD RD STE C211
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9336
Mailing Address - Country:US
Mailing Address - Phone:801-563-1975
Mailing Address - Fax:801-563-1984
Practice Address - Street 1:8822 SO REDWOOD RD
Practice Address - Street 2:C211
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8811
Practice Address - Country:US
Practice Address - Phone:801-563-1975
Practice Address - Fax:801-563-1984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT319791-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD1713Medicaid
UTD3859Medicaid
UTD5092Medicaid
UT07027Medicaid
UTD3859Medicaid
H68199Medicare UPIN
UTD5092Medicaid
H51756Medicare UPIN