=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447715701
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UTAH STATE UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2019
-----------------------------------------------------
Last Update Date | 04/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6405 OLD MAIN HILL
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84322-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-797-7430
-----------------------------------------------------
Fax | 844-308-5865
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6410 OLD MAIN HL
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84322-6410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-797-1346
-----------------------------------------------------
Fax | 844-308-5865
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL OFFICER
-----------------------------------------------------
Name | KATHRYN CLEMENTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 435-797-5830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------