=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871131623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IN HOME PROVIDER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2019
-----------------------------------------------------
Last Update Date | 12/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2432 CONCORD AVE
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84765-5621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-659-7352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 387 W 100 S
-----------------------------------------------------
City | HEBER CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84032-1835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-671-3285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | SHANE WHITTIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 435-709-8786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------