1689744138 NPI number — DR. KENT J NIELSEN AU.D.

Table of content: DR. KENT J NIELSEN AU.D. (NPI 1689744138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689744138 NPI number — DR. KENT J NIELSEN AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIELSEN
Provider First Name:
KENT
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
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:
1689744138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 S FAIRFIELD RD STE 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAYTON
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84041-4495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-294-6200
Provider Business Mailing Address Fax Number:
801-497-9301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3651 WALL AVE
Provider Second Line Business Practice Location Address:
NEWGATE MALL
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84405-2014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-612-0202
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2006

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: 237600000X , with the licence number:  108649-4101 , 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: 10864941003001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 80601 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: PRO7581 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1689744138 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10864941004001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 224962 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 10864941006001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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