1558650333 NPI number — MISS SHIRLEY ROSE ELEY SSW

Table of content: MISS SHIRLEY ROSE ELEY SSW (NPI 1558650333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558650333 NPI number — MISS SHIRLEY ROSE ELEY SSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELEY
Provider First Name:
SHIRLEY
Provider Middle Name:
ROSE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
SSW
Provider Gender Code:
F

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:
1558650333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1141 E 3900 S
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:
84124-1215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-284-4900
Provider Business Mailing Address Fax Number:
801-284-4901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1141 EAST 3900 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-284-4900
Provider Business Practice Location Address Fax Number:
801-284-4901
Provider Enumeration Date:
04/01/2011

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: 104100000X , with the licence number:  331819-3503 , 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)