1528070489 NPI number — MOAB FAMILY MEDICINE PC

Table of content: (NPI 1528070489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528070489 NPI number — MOAB FAMILY MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOAB FAMILY MEDICINE PC
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:
1528070489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
476 WILLIAMS WAY STE A
Provider Second Line Business Mailing Address:
PO BOX 1270
Provider Business Mailing Address City Name:
MOAB
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84532-2065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-259-7121
Provider Business Mailing Address Fax Number:
435-259-3112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
476 WILLIAMS WAY
Provider Second Line Business Practice Location Address:
A
Provider Business Practice Location Address City Name:
MOAB
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84532-2065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-259-7121
Provider Business Practice Location Address Fax Number:
435-259-3112
Provider Enumeration Date:
08/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
LEWIS
Authorized Official Title or Position:
OWNER/PHYSICIAN/PARTNER
Authorized Official Telephone Number:
435-259-7121

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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: 1542 . This is a "BUSINESS LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 46D1056014 . This is a "CLIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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