1790306462 NPI number — SUNSET LIVING LLC

Table of content: CHARLES R FORTNER RPH (NPI 1578521134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790306462 NPI number — SUNSET LIVING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNSET LIVING 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:
1790306462
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1614
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPANISH FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84660-7614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-360-4118
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
409 S 300 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTAQUIN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84655-8156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-754-3995
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MCGRAW
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
801-360-4118

Provider Taxonomy Codes

  • Taxonomy code: 3104A0630X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2020-ALII-UT207340 . This is a "UTAH STATE HEALTH DEPARTMENT" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 9357132-0160 . This is a "UTAH STATE BUSINESS LICENSING" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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