1982722443 NPI number — BRENT L. HADLOCK, OD, PC

Table of content: (NPI 1982722443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982722443 NPI number — BRENT L. HADLOCK, OD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRENT L. HADLOCK, OD, PC
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:
1982722443
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:
1448 S STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OREM
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84097-7704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-224-0451
Provider Business Mailing Address Fax Number:
801-224-0452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1448 S STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREM
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84097-7704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-224-0451
Provider Business Practice Location Address Fax Number:
801-224-0452
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HADLOCK
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
801-224-0451

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  110079-9934 , 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: 519526886017 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com