1790044592 NPI number — LYNX MEDICAL SERVICES ORGANIZATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790044592 NPI number — LYNX MEDICAL SERVICES ORGANIZATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LYNX MEDICAL SERVICES ORGANIZATION
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:
6
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:
1790044592
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 E 2100 S
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:
84106-1829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-909-5866
Provider Business Mailing Address Fax Number:
801-665-1882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3066 E MERIDIAN PARK LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654-7299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-357-9590
Provider Business Practice Location Address Fax Number:
907-357-9593
Provider Enumeration Date:
05/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CRANE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
800-909-5866

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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