1194978015 NPI number — CREEKSIDE MEDICAL EQUIPMENT & SUPPLIES

Table of content: (NPI 1194978015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194978015 NPI number — CREEKSIDE MEDICAL EQUIPMENT & SUPPLIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREEKSIDE MEDICAL EQUIPMENT & SUPPLIES
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:
1194978015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4232 S 500 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84123-1336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-263-1400
Provider Business Mailing Address Fax Number:
801-263-9390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
376 SUNLAND DR
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
ST GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84790-5612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-673-5540
Provider Business Practice Location Address Fax Number:
435-673-5052
Provider Enumeration Date:
10/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
SIONE
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
435-673-5540

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  5326946-1703 , 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: 870431335009 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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