1366597866 NPI number — JOSEPH F DECKER PROFESSIONAL CORP

Table of content: (NPI 1366597866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366597866 NPI number — JOSEPH F DECKER PROFESSIONAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSEPH F DECKER PROFESSIONAL CORP
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:
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:
1366597866
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1365 SUMAC DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84321-4819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-753-3277
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
164 S 5TH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTPELIER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-753-3277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DECKER
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
435-753-3277

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  M3611 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 80515 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010001738 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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