1700135233 NPI number — SOUTH JORDAN HEALTH AND WELLNESS

Table of content: (NPI 1700135233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700135233 NPI number — SOUTH JORDAN HEALTH AND WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH JORDAN HEALTH AND WELLNESS
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:
1700135233
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
272 N BROADWAY ST
Provider Second Line Business Mailing Address:
#11
Provider Business Mailing Address City Name:
TOOELE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84074-2244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-882-1621
Provider Business Mailing Address Fax Number:
435-882-8267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
272 N BROADWAY ST
Provider Second Line Business Practice Location Address:
#11
Provider Business Practice Location Address City Name:
TOOELE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84074-2244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-882-1621
Provider Business Practice Location Address Fax Number:
435-882-8267
Provider Enumeration Date:
08/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSON
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
435-882-1621

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  370378-1202 , 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: 3703781202 . This is a "STATE LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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