1295826865 NPI number — SOUTHERN UTAH UNIVERSITY

Table of content: (NPI 1295826865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295826865 NPI number — SOUTHERN UTAH UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN UTAH UNIVERSITY
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:
1295826865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 142001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84114-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-856-6070
Provider Business Mailing Address Fax Number:
435-586-5232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2390 W HWY 56
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
CEDAR CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-586-6070
Provider Business Practice Location Address Fax Number:
435-586-5232
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVENPORT
Authorized Official First Name:
VERGEANIA
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
PROGRAM MANAGER
Authorized Official Telephone Number:
435-586-6070

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  N/A ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8760000545631 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: HT001413-001 . This is a "PARTNER ID" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com