Provider Demographics
NPI:1699760140
Name:STRATA MEDICAL LLC
Entity type:Organization
Organization Name:STRATA MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:S
Authorized Official - Last Name:HUMES
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:435-684-2288
Mailing Address - Street 1:80 W MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-2814
Mailing Address - Country:US
Mailing Address - Phone:435-613-6500
Mailing Address - Fax:435-613-6515
Practice Address - Street 1:4313 BULLFROG
Practice Address - Street 2:NPS DRO HWY 276
Practice Address - City:LAKE POWELL
Practice Address - State:UT
Practice Address - Zip Code:84533
Practice Address - Country:US
Practice Address - Phone:435-684-2288
Practice Address - Fax:435-684-2239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1018291206261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
274986Medicare ID - Type Unspecified
R61219Medicare UPIN