1114928868 NPI number — BEVAN D BLAKE PT, DPT

Table of content: BEVAN D BLAKE PT, DPT (NPI 1114928868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114928868 NPI number — BEVAN D BLAKE PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
BEVAN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
M

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:
1114928868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
370 E SOUTH TEMPLE
Provider Second Line Business Mailing Address:
#250
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84111-1206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-512-2656
Provider Business Mailing Address Fax Number:
801-906-0336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 E SOUTH TEMPLE
Provider Second Line Business Practice Location Address:
#250
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:
84111-1206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-512-2656
Provider Business Practice Location Address Fax Number:
801-906-0336
Provider Enumeration Date:
08/03/2005

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: 225100000X , with the licence number:  344859-2401 , 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: 64-00731 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 68963 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870388269BR1 . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: CJ9402 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 34485924000001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 5417 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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