1790370955 NPI number — CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION

Table of content: (NPI 1790370955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790370955 NPI number — CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
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:
1790370955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
660 S 200 E STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84111-3846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3448 S 3200 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST VALLEY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84119-2628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-359-2256
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CONTRERAS
Authorized Official First Name:
CRYSTAL
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
801-359-2256

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 119950086-1704 . This is a "STATE LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com