Healthcare Provider Details

I. General information

NPI: 1811054182
Provider Name (Legal Business Name): UTAH STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 N 800 E
LOGAN UT
84321-3634
US

IV. Provider business mailing address

809 N 800 E
LOGAN UT
84321-3634
US

V. Phone/Fax

Practice location:
  • Phone: 435-797-8532
  • Fax: 435-797-8530
Mailing address:
  • Phone: 435-797-8529
  • Fax: 435-797-8530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number0700020
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number0700020
License Number StateUT

VIII. Authorized Official

Name: DRAKE LEROY RASMUSSEN
Title or Position: PROGRAM COORDINATOR
Credential:
Phone: 435-797-8528