=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679745467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXPRESS POX L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2008
-----------------------------------------------------
Last Update Date | 04/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1896 E 5725 S
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-5905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-721-0415
-----------------------------------------------------
Fax | 801-479-7699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1896 E 5725 S
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-5905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-721-0415
-----------------------------------------------------
Fax | 801-479-7699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | ROGER W. HANSEN
-----------------------------------------------------
Credential | CRT
-----------------------------------------------------
Telephone | 801-721-0415
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 103889-5701
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------