1619526811 NPI number — RED ROCK MEDICAL SUPPLY LLC

Table of content: (NPI 1619526811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619526811 NPI number — RED ROCK MEDICAL SUPPLY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED ROCK MEDICAL SUPPLY LLC
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:
6
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:
1619526811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 S 900 E STE 100
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:
84102-2983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-886-9700
Provider Business Mailing Address Fax Number:
801-415-9423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1763 W MARCON LN STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-886-9700
Provider Business Practice Location Address Fax Number:
801-415-9423
Provider Enumeration Date:
09/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
LISKEY
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
801-886-9700

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1396018545 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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