Provider Demographics
NPI:1972644540
Name:JAMES L. POULTON, PH.D., P.C., INC.
Entity type:Organization
Organization Name:JAMES L. POULTON, PH.D., P.C., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:POULTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-350-0117
Mailing Address - Street 1:850 E 300 S
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2332
Mailing Address - Country:US
Mailing Address - Phone:801-350-0117
Mailing Address - Fax:801-350-3536
Practice Address - Street 1:850 E 300 S
Practice Address - Street 2:SUITE 10
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2332
Practice Address - Country:US
Practice Address - Phone:801-350-0117
Practice Address - Fax:801-350-3536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114917-2501261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000007423Medicare PIN