Basic Information
| Provider Information | |||||||||
| NPI: | 1851416838 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL VALLEY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CENTRAL VALLEY MEDICAL CENTER SWING | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 48 W 1500 N | ||||||||
| Address2: | PO BOX 412 | ||||||||
| City: | NEPHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846488900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356233000 | ||||||||
| FaxNumber: | 4356233123 | ||||||||
| Practice Location | |||||||||
| Address1: | 48 W 1500 N | ||||||||
| Address2: | |||||||||
| City: | NEPHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846488900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356233000 | ||||||||
| FaxNumber: | 4356233123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STODDARD | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4356233000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 2005-HOSP-171 | UT | Y | Hospital Units | Medicare Defined Swing Bed Unit |
No ID Information.