1407969454 NPI number — MS. VICKIE L BRUNSTETTER O.T.

Table of content: MS. VICKIE L BRUNSTETTER O.T. (NPI 1407969454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407969454 NPI number — MS. VICKIE L BRUNSTETTER O.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNSTETTER
Provider First Name:
VICKIE
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
O.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407969454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 510721
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84151-0721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-587-6872
Provider Business Mailing Address Fax Number:
801-587-6675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 N MEDICAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84132-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-581-2121
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  91-108672-4201 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10867242000001 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".