1972992477 NPI number — COTTONWOOD MEDICAL CLINIC,PLLC

Table of content: (NPI 1972992477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972992477 NPI number — COTTONWOOD MEDICAL CLINIC,PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COTTONWOOD MEDICAL CLINIC,PLLC
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:
1972992477
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8414 S KINGS COVE DR
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:
84121-6064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-231-4932
Provider Business Mailing Address Fax Number:
866-936-0188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6671 S REDWOOD RD
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
WEST JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84084-7488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-571-2452
Provider Business Practice Location Address Fax Number:
866-936-0188
Provider Enumeration Date:
01/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LAPOLLA
Authorized Official First Name:
ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-231-4932

Provider Taxonomy Codes

  • Taxonomy code: 364SA2100X , with the licence number:  2121144405 , 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: 2121144405 . This is a "STATE LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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