Provider Demographics
NPI:1396444337
Name:MILLCREEK PDC PLLC
Entity type:Organization
Organization Name:MILLCREEK PDC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-305-3460
Mailing Address - Street 1:PO BOX 970681
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-0681
Mailing Address - Country:US
Mailing Address - Phone:801-506-6354
Mailing Address - Fax:
Practice Address - Street 1:4110 S HIGHLAND DR STE 100A
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84124-2784
Practice Address - Country:US
Practice Address - Phone:801-506-6354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental