1699224121 NPI number — COTTONWOOD DIAGNOSTICS LLP

Table of content: MR. SAM H. BOYAJIAN RPH (NPI 1114039245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699224121 NPI number — COTTONWOOD DIAGNOSTICS LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COTTONWOOD DIAGNOSTICS LLP
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:
1699224121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12351 S GATEWAY PARK PL
Provider Second Line Business Mailing Address:
SUITE D-700
Provider Business Mailing Address City Name:
DRAPER
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84020-9581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-201-1763
Provider Business Mailing Address Fax Number:
801-683-9907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12351 S GATEWAY PARK PL
Provider Second Line Business Practice Location Address:
SUITE D-600
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020-9581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-201-1763
Provider Business Practice Location Address Fax Number:
801-683-9907
Provider Enumeration Date:
09/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MURANO
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-201-1763

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 46D2118660 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 027544 . This is a "COLA" identifier . This identifiers is of the category "OTHER".




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