1558463323 NPI number — JACK WYNN ROLFE PT

Table of content: NASIR ASIF (NPI 1356181242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558463323 NPI number — JACK WYNN ROLFE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROLFE
Provider First Name:
JACK
Provider Middle Name:
WYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1558463323
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 711185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-942-2729
Provider Business Mailing Address Fax Number:
801-942-5955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 NORTH 1680 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-674-1269
Provider Business Practice Location Address Fax Number:
435-674-1269
Provider Enumeration Date:
09/02/2006

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: 225100000X , with the licence number:  1140732401 , 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: D4211 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com