1871500504 NPI number — MLMS DOWNTOWN CLINIC LC

Table of content: MRS. MONICA MCGEE KELLER B.S. (NPI 1548375025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871500504 NPI number — MLMS DOWNTOWN CLINIC LC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MLMS DOWNTOWN CLINIC LC
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:
MOUNTAIN LAND REHABILITATION
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:
1871500504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
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:
801-942-3311
Provider Business Mailing Address Fax Number:
801-942-5955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1153 E 3900 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-262-6331
Provider Business Practice Location Address Fax Number:
801-262-3372
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
801-942-3311

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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