Provider Demographics
NPI:1538946207
Name:SOUTH PROVO PDC PLLC
Entity type:Organization
Organization Name:SOUTH PROVO PDC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BETANCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-305-3465
Mailing Address - Street 1:PO BOX 970185
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-0185
Mailing Address - Country:US
Mailing Address - Phone:801-691-1701
Mailing Address - Fax:801-355-6551
Practice Address - Street 1:2211 E VALLEY VISTA WAY
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5636
Practice Address - Country:US
Practice Address - Phone:385-412-6964
Practice Address - Fax:385-248-5034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-14
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental