1366789059 NPI number — JARED MORONI CASEY

Table of content: JARED MORONI CASEY (NPI 1366789059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366789059 NPI number — JARED MORONI CASEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASEY
Provider First Name:
JARED
Provider Middle Name:
MORONI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1366789059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
763 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALPINE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84004-1113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-867-1515
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 E STATE ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEHI
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84043-1625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-407-9998
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/15/2013

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: 103TC1900X , with the licence number:  6019771-3902 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 6019771-3902 , 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)