Provider Demographics
NPI:1548302268
Name:ADVANCED PRACTICE MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:ADVANCED PRACTICE MEDICAL CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAND
Authorized Official - Middle Name:PAXTON
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:435-843-8881
Mailing Address - Street 1:491 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-1654
Mailing Address - Country:US
Mailing Address - Phone:435-843-8881
Mailing Address - Fax:435-843-8802
Practice Address - Street 1:491 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-0922
Practice Address - Country:US
Practice Address - Phone:435-843-8881
Practice Address - Fax:435-843-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT271062-4405261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP17856Medicare UPIN
000057806Medicare ID - Type Unspecified