Provider Demographics
NPI:1043421753
Name:TRI CITY MEDICAL CLINIC INC
Entity type:Organization
Organization Name:TRI CITY MEDICAL CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-756-3511
Mailing Address - Street 1:447 E 1000 S
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-3623
Mailing Address - Country:US
Mailing Address - Phone:801-756-3511
Mailing Address - Fax:801-756-1705
Practice Address - Street 1:447 E 1000 S
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3623
Practice Address - Country:US
Practice Address - Phone:801-756-3511
Practice Address - Fax:801-756-1705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========Medicaid
000055159Medicare PIN
UT1018060001Medicare NSC