1366557407 NPI number — ROBERT L LANGSTON CRNA

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366557407 NPI number — ROBERT L LANGSTON CRNA

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

LANGSTON

Provider First Name:

ROBERT

Provider Middle Name:

L

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

CRNA

Provider Gender Code:

M

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:

1366557407

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/21/2009

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

65 W 850 S

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CENTERVILLE

Provider Business Mailing Address State Name:

UT

Provider Business Mailing Address Postal Code:

84014-2198

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

801-733-2155

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

3460 PIONEER PKWY

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

WEST VALLEY CITY

Provider Business Practice Location Address State Name:

UT

Provider Business Practice Location Address Postal Code:

84120-2049

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

801-993-9526

Provider Business Practice Location Address Fax Number:

801-733-5872

Provider Enumeration Date:

08/20/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 367500000X , with the licence number:  212994-4406 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 24053 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: PR00660 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 004373400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
• Identifier: 117819900 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
• Identifier: 350411 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 53000 . This is a "HEALTHY U" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 870532396LA1 . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 190400800 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: QM0000023694 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 2000012 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 200611540A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".