1487202867 NPI number — LEOPOLDO MIRANDA DELATORRE LMT

Table of content: LEOPOLDO MIRANDA DELATORRE LMT (NPI 1487202867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487202867 NPI number — LEOPOLDO MIRANDA DELATORRE LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELATORRE
Provider First Name:
LEOPOLDO
Provider Middle Name:
MIRANDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DE LA TORRE
Provider Other First Name:
LEO
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1487202867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1702 E 5600 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH OGDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84403-4384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-689-2546
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5261 ADAMS AVE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON TERRACE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84405-6748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-475-7733
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2019

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: 225700000X , with the licence number:  9730693-4701 , 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)





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