=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518244086
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DHHS IHS PHOENIX AREA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2011
-----------------------------------------------------
Last Update Date | 11/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6822 EAST 1000 SOUTH
-----------------------------------------------------
City | FORT DUCHESNE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-828-5214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 160
-----------------------------------------------------
City | FORT DUCHESNE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84026-0160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACTING CEO
-----------------------------------------------------
Name | STEVE PEHRSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 435-828-5214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP0904X
-----------------------------------------------------
Taxonomy Name | Federal Public Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------