1043612252 NPI number — GRAYDON WICKMAN ATC-L, LMT, CSS

Table of content: GRAYDON WICKMAN ATC-L, LMT, CSS (NPI 1043612252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043612252 NPI number — GRAYDON WICKMAN ATC-L, LMT, CSS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKMAN
Provider First Name:
GRAYDON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC-L, LMT, CSS
Provider Gender Code:
M

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:
1043612252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3336 S PIONEER PKWY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
WEST VALLEY CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84120-2000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-964-3100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3336 S PIONEER PKWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WEST VALLEY CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84120-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-964-3100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  514032-4810 , 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)





Copyright © 2007-2024 www.npivalidator.com