1912234865 NPI number — RANDY RAY ENTERPRISES LLC

Table of content: (NPI 1912234865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912234865 NPI number — RANDY RAY ENTERPRISES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDY RAY ENTERPRISES 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:
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:
1912234865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2936 LAKE MARY DR
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:
84121-5331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-860-9627
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3900 SOUTH AVENUE, 220 EAST AVENUE
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-738-4369
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PARTNER/PROGRAM DIRECTOR
Authorized Official Telephone Number:
801-738-4369

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  59432763902 , 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: 11798095 . This is a "CAQH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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