Basic Information
| Provider Information | |||||||||
| NPI: | 1285994400 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VETERANS ADMINISTRATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 BERKELEY ST | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841083201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
| FaxNumber: | 8015821565 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 BERKELEY ST. | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
| FaxNumber: | 8015842576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2012 | ||||||||
| LastUpdateDate: | 05/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | STOVALL | ||||||||
| AuthorizedOfficialFirstName: | SHELLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF NURSING | ||||||||
| AuthorizedOfficialTelephone: | 8015821565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 213999-3102 | UT | Y | Hospitals | General Acute Care Hospital |
No ID Information.