1770905705 NPI number — EMERE UTAH, LLC

Table of content: (NPI 1770905705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770905705 NPI number — EMERE UTAH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERE UTAH, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1770905705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1468
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOUNTIFUL
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84011-1468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-296-2113
Provider Business Mailing Address Fax Number:
801-296-1715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5296 S COMMERCE DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-4767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
385-474-8888
Provider Business Practice Location Address Fax Number:
801-590-8123
Provider Enumeration Date:
01/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
COTTLE
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
801-617-2100

Provider Taxonomy Codes

  • Taxonomy code: 2081S0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1770905705 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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