Provider Demographics
NPI:1730630203
Name:CLINICAL CONSULTANTS LLC
Entity type:Organization
Organization Name:CLINICAL CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:ASUDC
Authorized Official - Phone:801-233-8670
Mailing Address - Street 1:7601 S REDWOOD RD BLDG E
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-4007
Mailing Address - Country:US
Mailing Address - Phone:801-233-8670
Mailing Address - Fax:
Practice Address - Street 1:7601 S REDWOOD RD BLDG E
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-4007
Practice Address - Country:US
Practice Address - Phone:801-233-8670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLINICAL CONSULTANTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT22529261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)