Healthcare Provider Details

I. General information

NPI: 1295855914
Provider Name (Legal Business Name): NIGHT LIGHT PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 E 100 S STE 14
ST GEORGE UT
84790-3005
US

IV. Provider business mailing address

1240 E 100 S STE 14
ST GEORGE UT
84790-3005
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-8034
  • Fax:
Mailing address:
  • Phone: 435-628-8034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number88-178110-1205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier09165
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: DR. JERRY D TWIGGS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 435-628-8034