1790010619 NPI number — ASHLEY VALLEY PHYSICIAN PRACTICE, LLC

Table of content: (NPI 1790010619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790010619 NPI number — ASHLEY VALLEY PHYSICIAN PRACTICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASHLEY VALLEY PHYSICIAN PRACTICE, 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:
6
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:
1790010619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 SEVEN SPRINGS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-920-7000
Provider Business Mailing Address Fax Number:
615-920-8775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 W 100 N
Provider Second Line Business Practice Location Address:
SUITE 102S
Provider Business Practice Location Address City Name:
VERNAL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84078-2036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-781-2161
Provider Business Practice Location Address Fax Number:
435-781-2162
Provider Enumeration Date:
10/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LAWRENCE
Authorized Official First Name:
CHARLOTTE
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
615-920-7000

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , 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)





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