1114137049 NPI number — EDWARD STEVENSON LSAC

Table of content: EDWARD STEVENSON LSAC (NPI 1114137049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114137049 NPI number — EDWARD STEVENSON LSAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENSON
Provider First Name:
EDWARD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STEVENSON
Provider Other First Name:
EDDIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LSAC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1114137049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
474 W 200 N
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ST GEORGE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84770-4505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-634-5600
Provider Business Mailing Address Fax Number:
435-986-8700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
474 W 200 N
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ST GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84770-4505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-634-5600
Provider Business Practice Location Address Fax Number:
435-986-8700
Provider Enumeration Date:
05/22/2007

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: STEVEE . This is a "SBHC STAFF CODE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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