1053647610 NPI number — LESLIE MARIE MILLER

Table of content: LESLIE MARIE MILLER (NPI 1053647610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053647610 NPI number — LESLIE MARIE MILLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
LESLIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSEN
Provider Other First Name:
LESLIE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053647610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4650 HARRISON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OGDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84403-4303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-475-3870
Provider Business Mailing Address Fax Number:
801-475-3876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1186 E 4600 S STE 320
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84403-4303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-475-3870
Provider Business Practice Location Address Fax Number:
801-475-3876
Provider Enumeration Date:
11/02/2009

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: 225200000X , with the licence number:  374958-8019 , 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)