1841393972 NPI number — INTERMOUNTAIN ALLERGY & IMMUNOLOGY CLINIC

Table of content: (NPI 1841393972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841393972 NPI number — INTERMOUNTAIN ALLERGY & IMMUNOLOGY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERMOUNTAIN ALLERGY & IMMUNOLOGY CLINIC
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:
1841393972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5929 FASHION POINT DR
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
SOUTH OGDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84403-4672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-476-0052
Provider Business Mailing Address Fax Number:
801-476-0064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5929 FASHION POINT DR
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
SOUTH OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84403-4672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-476-0052
Provider Business Practice Location Address Fax Number:
801-476-0064
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
DUANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
801-363-4071

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DA3060 . This is a "GROUP RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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