1245211572 NPI number — MR. BRANDON M HEPNER PT

Table of content: MR. BRANDON M HEPNER PT (NPI 1245211572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245211572 NPI number — MR. BRANDON M HEPNER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEPNER
Provider First Name:
BRANDON
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1245211572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3497
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STURTEVANT
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53177-0300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-552-2996
Provider Business Mailing Address Fax Number:
866-245-8064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5991 S 3500 W
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
ROY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-985-2700
Provider Business Practice Location Address Fax Number:
801-985-2707
Provider Enumeration Date:
11/14/2005

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: 225100000X , with the licence number:  4553570-2401 , 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: 1245211572 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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