1184969883 NPI number — MR. DEE MILTON MARBLE SUDC

Table of content: MR. DEE MILTON MARBLE SUDC (NPI 1184969883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184969883 NPI number — MR. DEE MILTON MARBLE SUDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARBLE
Provider First Name:
DEE
Provider Middle Name:
MILTON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SUDC
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:
1184969883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 699
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-593-6777
Provider Business Mailing Address Fax Number:
801-544-0200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
845 WEST 200 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KAYSVILLE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-593-6777
Provider Business Practice Location Address Fax Number:
801-544-0200
Provider Enumeration Date:
12/06/2012

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: 101YA0400X , with the licence number:  2784686-6005 , 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)