Healthcare Provider Details

I. General information

NPI: 1619145455
Provider Name (Legal Business Name): US AIR FORCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 W 1280 S
PROVO UT
84601-6518
US

IV. Provider business mailing address

831 W 1280 S
PROVO UT
84601-6518
US

V. Phone/Fax

Practice location:
  • Phone: 801-373-9947
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number590260-1205
License Number StateUT

VIII. Authorized Official

Name: DAVID JASON CASSAT
Title or Position: FAMLIY PRACTICE
Credential: MD
Phone: 801-373-9947