=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487687430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERMOUNTAIN SKIN CANCER & ESTHETICS CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 01/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3860 JACKSON AVE STE 2
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-1997
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-627-0515
-----------------------------------------------------
Fax | 801-627-0517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3860 JACKSON AVE SUITE 2
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-1956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-627-0515
-----------------------------------------------------
Fax | 801-627-0517
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | DR. DAVID EDGAR ALLEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 801-627-0515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 159426-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 323171-1206
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 5316026-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------