Healthcare Provider Details

I. General information

NPI: 1487691002
Provider Name (Legal Business Name): SALT LAKE CITY VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S 11TH AVE
POCATELLO ID
83201-4835
US

IV. Provider business mailing address

PO BOX 94463
CLEVELAND OH
44101-4463
US

V. Phone/Fax

Practice location:
  • Phone: 913-578-4409
  • Fax:
Mailing address:
  • Phone: 913-578-4409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIN POTTER
Title or Position: NPI TEAM MEMBER
Credential:
Phone: 202-382-2579