1902975121 NPI number — BRADLEY V FELLOWS INC

Table of content: JOSEPH DLUGOSZ CRNA (NPI 1497771729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902975121 NPI number — BRADLEY V FELLOWS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADLEY V FELLOWS INC
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:
VISION CARE CENTERS
Provider Other Organization Name Type Code:
3
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:
1902975121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9035 SOUTH 1300 EAST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SANDY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-566-4119
Provider Business Mailing Address Fax Number:
801-568-3844

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9035 SOUTH 1300 EAST
Provider Second Line Business Practice Location Address:
100
Provider Business Practice Location Address City Name:
SANDY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-619-9494
Provider Business Practice Location Address Fax Number:
801-619-9546
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FELLOWS
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
V
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
801-566-4119

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1135088908 , 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: 524900806001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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