1669425146 NPI number — L. SCOTT VANWAGONER DO

Table of content: L. SCOTT VANWAGONER DO (NPI 1669425146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669425146 NPI number — L. SCOTT VANWAGONER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANWAGONER
Provider First Name:
L. SCOTT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1669425146
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 430
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:
84660-0430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-898-7136
Provider Business Mailing Address Fax Number:
616-975-9827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 NORTH 1100 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMERICAN FORK
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-714-6570
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2006

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: 207PE0004X , with the licence number:  359724 , 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: 659871 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870636000VA1 . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107009651102 . This is a "SELECT HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: D2495 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com