1326418328 NPI number — DDMS OF UTAH NO.2

Table of content: (NPI 1326418328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326418328 NPI number — DDMS OF UTAH NO.2

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DDMS OF UTAH NO.2
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:
1326418328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 S PACIFIC DR
Provider Second Line Business Mailing Address:
119
Provider Business Mailing Address City Name:
AMERICAN FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84003-2196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-763-9299
Provider Business Mailing Address Fax Number:
801-763-1121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 N 100 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOUNTIFUL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84010-6054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-292-6797
Provider Business Practice Location Address Fax Number:
801-295-3660
Provider Enumeration Date:
10/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BUCK
Authorized Official First Name:
MISTI
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
801-763-9299

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  2015-SHCF-344 , 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: 2015-SHCF-344 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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