Provider Demographics
NPI:1144928854
Name:AFFINITY HEALTHCARE, INC.
Entity type:Organization
Organization Name:AFFINITY HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAVAL
Authorized Official - Middle Name:B
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-276-0888
Mailing Address - Street 1:2380 N 400 E STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1756
Mailing Address - Country:US
Mailing Address - Phone:435-276-0888
Mailing Address - Fax:
Practice Address - Street 1:2380 N 400 E STE B
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1756
Practice Address - Country:US
Practice Address - Phone:435-276-0888
Practice Address - Fax:823-471-4536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-21
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3006721Medicaid
UT4201995Medicaid