1114154622 NPI number — PERSONAL PERFORMANCE MEDICAL CORPORATION

Table of content: (NPI 1114154622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114154622 NPI number — PERSONAL PERFORMANCE MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERSONAL PERFORMANCE MEDICAL CORPORATION
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:
1114154622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7575 S 900 E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDVALE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84047-2343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-364-3100
Provider Business Mailing Address Fax Number:
801-872-5714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3354 HARRISON BLVD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84403-1296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-334-6000
Provider Business Practice Location Address Fax Number:
801-317-4019
Provider Enumeration Date:
06/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-364-3100

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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