1114203668 NPI number — OGDEN CLINIC SPECIALTY SERVICES LLC

Table of content: (NPI 1114203668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114203668 NPI number — OGDEN CLINIC SPECIALTY SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OGDEN CLINIC SPECIALTY SERVICES 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:
OGDEN CLINIC PC
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:
1114203668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5546
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80217-5546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-475-3481
Provider Business Mailing Address Fax Number:
801-475-3494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4650 HARRISON BLVD
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:
801-475-3000
Provider Business Practice Location Address Fax Number:
801-475-3494
Provider Enumeration Date:
10/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
TINGEY
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
Authorized Official Title or Position:
BOARD PRESIDENT
Authorized Official Telephone Number:
801-475-3481

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 5776572-1206 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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