1356806517 NPI number — INTEGRATED MOBILE MEDICAL SUNCREST ADVANCED ILLNESS MANAGEMENT

Table of content: (NPI 1356806517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356806517 NPI number — INTEGRATED MOBILE MEDICAL SUNCREST ADVANCED ILLNESS MANAGEMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED MOBILE MEDICAL SUNCREST ADVANCED ILLNESS MANAGEMENT
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:
1356806517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 N 2100 W STE 202
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:
84116-4741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-924-8571
Provider Business Mailing Address Fax Number:
801-883-8044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5700 S QUEBEC ST STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD VLG
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80111-2008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-247-1600
Provider Business Practice Location Address Fax Number:
801-883-8044
Provider Enumeration Date:
02/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BURDICK
Authorized Official First Name:
GINIA
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
719-247-1600

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com