Provider Demographics
NPI:1780397224
Name:CRESCENT HEALTH CLINIC
Entity type:Organization
Organization Name:CRESCENT HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KANSAGRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-438-3255
Mailing Address - Street 1:11193 S REDWOOD RD STE 102N
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8208
Mailing Address - Country:US
Mailing Address - Phone:385-438-3255
Mailing Address - Fax:385-900-1234
Practice Address - Street 1:11193 S REDWOOD RD STE 102N
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8208
Practice Address - Country:US
Practice Address - Phone:385-438-3255
Practice Address - Fax:385-900-1234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-29
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty