Basic Information
Provider Information | |||||||||
NPI: | 1972865244 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUMAS | ||||||||
FirstName: | RAY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LAB TECH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 144 S 300 E | ||||||||
Address2: |   | ||||||||
City: | NORTH SALT LAKE | ||||||||
State: | UT | ||||||||
PostalCode: | 840541733 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013598862 | ||||||||
FaxNumber: | 8013598510 | ||||||||
Practice Location | |||||||||
Address1: | 144 S. 300 E. | ||||||||
Address2: |   | ||||||||
City: | NORTH SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 84054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013598862 | ||||||||
FaxNumber: | 8013598510 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2012 | ||||||||
LastUpdateDate: | 06/13/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1376550566 | UT | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 1376550566 | 05 | UT |   | MEDICAID |