1154376838 NPI number — BRENT WEBB

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154376838 NPI number — BRENT WEBB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEBB
Provider First Name:
BRENT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1154376838
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1466 FLINT CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KAYSVILLE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84037-9534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1452 E RIDGELINE DR
Provider Second Line Business Practice Location Address:
#51
Provider Business Practice Location Address City Name:
SOUTH OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84405-4946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-479-5777
Provider Business Practice Location Address Fax Number:
801-479-7005
Provider Enumeration Date:
05/23/2006

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:  120650-2401 , 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: TPRA10491 . This is a "MOLINA PROV # PROVO" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 577514 . This is a "DMBA PROV # OGDEN" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107001618103 . This is a "IHC ADVOCATES # PROVO" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 5577514 . This is a "DMBA PROV # PROVO" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: TPRA10491 . This is a "MOLINA PROV # OGDEN" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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