1790077642 NPI number — INTERCARE LLC

Table of content: (NPI 1790077642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790077642 NPI number — INTERCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERCARE 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:
1790077642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6694 W. NORMANDY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLAND
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-704-5027
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1317 E 750 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREM
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84097-5480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-704-5027
Provider Business Practice Location Address Fax Number:
801-367-7678
Provider Enumeration Date:
05/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BUNN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
801-704-5027

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  5756680-1204 , 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: DO195129 . This is a "OREGON MEDICAL LICESNSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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