1750732723 NPI number — COUNTRY LANE PAYSON OPERATING LLC

Table of content: (NPI 1750732723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750732723 NPI number — COUNTRY LANE PAYSON OPERATING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRY LANE PAYSON OPERATING 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:
1750732723
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1133 N. MAIN ST
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
LAYTON
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-546-7417
Provider Business Mailing Address Fax Number:
801-546-5230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
153 S. 900 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAYSON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-465-1490
Provider Business Practice Location Address Fax Number:
801-465-3579
Provider Enumeration Date:
06/30/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSEN
Authorized Official First Name:
JARED
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-928-3997

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  2016AL11UT207238 , 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)





Copyright © 2007-2025 www.npivalidator.com