1508072703 NPI number — METRO TREATMENT OF UTAH LP

Table of content: (NPI 1508072703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508072703 NPI number — METRO TREATMENT OF UTAH LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO TREATMENT OF UTAH LP
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:
LOGAN METRO TREATMENT CENTER
Provider Other Organization Name Type Code:
3
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:
1508072703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14050 TOWN LOOP BLVD
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32837-6190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-351-7080
Provider Business Mailing Address Fax Number:
407-351-6930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 N 200 E
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84341-2398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-755-5915
Provider Business Practice Location Address Fax Number:
435-775-5917
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
407-351-7080

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  11675 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0002X , with the licence number: 5888583-1704 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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