1336144096 NPI number — CANYONLANDS MEDICAL LC

Table of content: (NPI 1336144096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336144096 NPI number — CANYONLANDS MEDICAL LC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANYONLANDS MEDICAL LC
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:
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:
1336144096
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
285 W TABERNACLE ST
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
ST GEORGE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84770-3385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-634-7625
Provider Business Mailing Address Fax Number:
435-634-0716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
285 W TABERNACLE ST
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
ST GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84770-3385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-634-7625
Provider Business Practice Location Address Fax Number:
435-634-0716
Provider Enumeration Date:
06/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GREGORY
Authorized Official First Name:
EARLE
Authorized Official Middle Name:
SMITH
Authorized Official Title or Position:
OPERATIONS
Authorized Official Telephone Number:
435-634-7625

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  5528522-1703 , 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: 5528522-1703 . This is a "PHARMACY NUMBER" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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