1891973152 NPI number — DRY CREEK FAMILY PRACTICE

Table of content: (NPI 1891973152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891973152 NPI number — DRY CREEK FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRY CREEK FAMILY PRACTICE
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:
1891973152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 N. RUNNING CREEK WAY
Provider Second Line Business Mailing Address:
BUILDING B, SUITE 100
Provider Business Mailing Address City Name:
LEHI
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-766-4214
Provider Business Mailing Address Fax Number:
801-407-3052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 N. RUNNING CREEK WAY
Provider Second Line Business Practice Location Address:
BUILDING B, SUITE 100
Provider Business Practice Location Address City Name:
LEHI
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-766-4214
Provider Business Practice Location Address Fax Number:
801-407-3052
Provider Enumeration Date:
02/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SHARP
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-766-4214

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  3185351205 , 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: 029445370001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 264182 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 02944537007001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 5838465 . This is a "AETNA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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