Provider Demographics
NPI:1164676698
Name:COALVILLE HEALTH CENTER
Entity type:Organization
Organization Name:COALVILLE HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:D.
Authorized Official - Middle Name:WAIN
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-783-4385
Mailing Address - Street 1:PO BOX 865
Mailing Address - Street 2:142S 50 E SUITE 102
Mailing Address - City:COALVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84017-0865
Mailing Address - Country:US
Mailing Address - Phone:435-336-4403
Mailing Address - Fax:435-336-5570
Practice Address - Street 1:142 S 50 EAST SUITE 102
Practice Address - Street 2:POB 865
Practice Address - City:COALVILLE
Practice Address - State:UT
Practice Address - Zip Code:84017-0865
Practice Address - Country:US
Practice Address - Phone:435-336-4403
Practice Address - Fax:435-336-5570
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COALVILLE HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1713511205261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty