Provider Demographics
NPI:1285003335
Name:SAGE CLINIC
Entity type:Organization
Organization Name:SAGE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LATSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-441-1002
Mailing Address - Street 1:560 S 300 E STE 275
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3586
Mailing Address - Country:US
Mailing Address - Phone:801-441-1002
Mailing Address - Fax:
Practice Address - Street 1:7285 WEST 21200 NORTH
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:UT
Practice Address - Zip Code:84330
Practice Address - Country:US
Practice Address - Phone:435-458-9205
Practice Address - Fax:435-458-2361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT70619161204261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care