1699224121 NPI number — COTTONWOOD DIAGNOSTICS LLP

Table of content: (NPI 1699224121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699224121 NPI number — COTTONWOOD DIAGNOSTICS LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COTTONWOOD DIAGNOSTICS LLP
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:
1699224121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12351 S GATEWAY PARK PL
Provider Second Line Business Mailing Address:
SUITE D-700
Provider Business Mailing Address City Name:
DRAPER
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84020-9581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-201-1763
Provider Business Mailing Address Fax Number:
801-683-9907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12351 S GATEWAY PARK PL
Provider Second Line Business Practice Location Address:
SUITE D-600
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020-9581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-201-1763
Provider Business Practice Location Address Fax Number:
801-683-9907
Provider Enumeration Date:
09/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MURANO
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-201-1763

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 46D2118660 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 027544 . This is a "COLA" identifier . This identifiers is of the category "OTHER".




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