1093716680 NPI number — STEVEN M WIXOM PT, DPT, CHT

Table of content: STEVEN M WIXOM PT, DPT, CHT (NPI 1093716680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093716680 NPI number — STEVEN M WIXOM PT, DPT, CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIXOM
Provider First Name:
STEVEN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, CHT
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:
1093716680
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5151 S 900 E
Provider Second Line Business Mailing Address:
#100
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84117-6657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-261-3321
Provider Business Mailing Address Fax Number:
801-261-5942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 E SOUTH TEMPLE
Provider Second Line Business Practice Location Address:
#102
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:
84102-1204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-328-8535
Provider Business Practice Location Address Fax Number:
801-364-1242
Provider Enumeration Date:
08/03/2005

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: 2251H1200X , with the licence number:  275343-2401 , 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: CJ9402 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 27534324000001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 6400654 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 69156 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 5417 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1108540001 . This is a "CIGNA DMERC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870388269BR1 . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com