Provider Demographics
NPI:1164857843
Name:THE COMMUNITY HEALTH CLINIC, LLC
Entity type:Organization
Organization Name:THE COMMUNITY HEALTH CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:TULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LDEM
Authorized Official - Phone:801-380-3247
Mailing Address - Street 1:382 E 400 S # C
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-1958
Mailing Address - Country:US
Mailing Address - Phone:801-380-3247
Mailing Address - Fax:
Practice Address - Street 1:382 E 400 S # C
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-1958
Practice Address - Country:US
Practice Address - Phone:801-380-3247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 261QC1500X, 261QM0850X
UT6088135-3501261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health