MEDICARE: STATE OF UTAH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251K00000X	Public Health or Welfare Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699878942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF UTAH

Provider Business Mailing Address
First Line	:	PO BOX 142001
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84114-2001
Country	:	US
Telephone Number	:	801-538-6709
Fax Number	:	801-538-6591

Provider Business Practice Location Address
First Line	:	44 N MARIO CAPPECI DRIVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84114
Country	:	US
Telephone Number	:	801-584-8239
Fax Number	:

Authorized Official
Title or Position	:	BUREAU DIRECTOR, FINANCIAL RESCOURC
Name	:	KIM L ROMERO
Credential	:
Telephone Number	:	801-538-6911

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	08/20/2009

Similar Medicare Providers

1437252491 — STATE OF UTAH, DEPARTMENT OF HEALTH
Practice Location Address:

SALT LAKE CLINIC - FAMILY DENTAL PLAN , 3195 SOUTH MAIN STREET, SUITE 200
SALT LAKE CITY, UT
84114

Practice Phone: 801-468-0342
Practice Fax:

1225131279 — DR. BLAIR LAMAR BYBEE M.D.
Practice Location Address:

44 N MEDIAL DRIVE , UTAH DEPARTMENT OF HEALTH
SALT LAKE CITY, UT
84114-4630

Practice Phone: 801-584-8246
Practice Fax:

1497912190 — JENNY ANN PEDERSEN M.S. CCC-A
Practice Location Address:

44 N. MARIO CAPECCHI DR.
SALT LAKE CITY, UT
84114

Practice Phone: 801-584-8215
Practice Fax: 801-584-8492

1952547408 — MRS. MARITZA SILVA ARCE-LARRETA APRN, MSN, RN
Practice Location Address:

288 N 1460 W
SALT LAKE CITY, UT
84114-2107

Practice Phone: 801-538-6990
Practice Fax: 801-538-9495

1265739551 — MS. NOEL KAY CAMERON SSW
Practice Location Address:

2001 S. STATE SUITE S1500 , SALT LAKE COUNTY AGING AND ADULT SERVICES
SALT LAKE CITY, UT
84114-4575

Practice Phone: 385-468-3291
Practice Fax: 385-468-3264

1649605601 — NATALIE HOLT ALLEN FNP-BC
Practice Location Address:

44 N MARIO CAPECCHI DR.
SALT LAKE CITY, UT
84114

Practice Phone: 801-584-8246
Practice Fax:

Directions to “STATE OF UTAH ” Practice Location

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