1619960663 NPI number — JQ MEDICAL SUPPLY, LLC

Table of content: (NPI 1619960663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619960663 NPI number — JQ MEDICAL SUPPLY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JQ 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:
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:
1619960663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1225 E FORT UNION BLVD STE 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDVALE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84047-1883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-942-8582
Provider Business Mailing Address Fax Number:
801-880-3634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6910 HIGHLAND DR
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
COTTONWOOD HEIGHTS
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84121-3060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-942-8582
Provider Business Practice Location Address Fax Number:
801-880-3634
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
THURMAN
Authorized Official First Name:
TRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF REVENUE CYCLE
Authorized Official Telephone Number:
801-942-8582

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  E42635 , 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)

  • Identifier: 3012912 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com