1568886000 NPI number — WAYNE COMMUNITY HEALTH CENTERS INC

Table of content: (NPI 1568886000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568886000 NPI number — WAYNE COMMUNITY HEALTH CENTERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNE COMMUNITY HEALTH CENTERS INC
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:
KAZAN IVAN W MEMORIAL CLINIC
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:
1568886000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 303
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BICKNELL
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84715-0303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-425-3744
Provider Business Mailing Address Fax Number:
435-425-3785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
570 E MOQUI LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESCALANTE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84726-0276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-826-4374
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTENSEN
Authorized Official First Name:
EVAN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
435-425-3744

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000055193 . This is a "MEDICARE PART B -" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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