1790711190 NPI number — MR. KREGG TYLER LUNT MSPT

Table of content: DANIELLE JASMIN OCAMPO (NPI 1326680018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790711190 NPI number — MR. KREGG TYLER LUNT MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNT
Provider First Name:
KREGG
Provider Middle Name:
TYLER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
M

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:
1790711190
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1335 NORTHFIELD RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
CEDAR CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84720-9390
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-865-1902
Provider Business Mailing Address Fax Number:
435-586-5176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1335 NORTHFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
CEDAR CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84720-9390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-865-1902
Provider Business Practice Location Address Fax Number:
435-586-5176
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  365460-2401 , 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: 36546024000001 . This is a "BLUE CROSS BLUE SHIELD TA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 107009169101 . This is a "SELECT HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 36546024004001 . This is a "BLUE CROSS BLUE SHIELD PP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7242295 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 694369 . This is a "DMBA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0183234 . This is a "WASHINGTON STATE LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 64-00712 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64479 . This is a "PEHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: PRA04973 . This is a "MOLINA HEALTH CARE" identifier . This identifiers is of the category "OTHER".




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