Healthcare Provider Details

I. General information

NPI: 1780086843
Provider Name (Legal Business Name): LITTLE VALLEY ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2014
Last Update Date: 09/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 E FISH HATCHERY RD
MANTUA UT
84324-4379
US

IV. Provider business mailing address

89 E FISH HATCHERY RD
MANTUA UT
84324-4379
US

V. Phone/Fax

Practice location:
  • Phone: 435-225-5836
  • Fax:
Mailing address:
  • Phone: 435-225-5836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number216299-4406
License Number StateUT

VIII. Authorized Official

Name: MR. EMMETT WAYNE SEXTON
Title or Position: OWNER
Credential: CRNA
Phone: 435-225-5836