Provider Demographics
NPI:1548267420
Name:MIDTOWN COMMUNITY HEALTH CENTER INC
Entity type:Organization
Organization Name:MIDTOWN COMMUNITY HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-334-2213
Mailing Address - Street 1:2240 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1511
Mailing Address - Country:US
Mailing Address - Phone:801-393-5355
Mailing Address - Fax:801-394-4609
Practice Address - Street 1:2240 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1511
Practice Address - Country:US
Practice Address - Phone:801-393-5355
Practice Address - Fax:801-394-4609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
UT00867511261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Not Answered261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870540037009Medicaid
UT870540037009Medicaid
UT=========012Medicaid