MEDICARE: MR. UBONG- ABASI JAMES EDEMENANG

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1790289486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. UBONG- ABASI JAMES EDEMENANG

Provider Business Mailing Address
First Line	:	4460 SOUTH HIGHLAND DRIVE
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84124-3503
Country	:	US
Telephone Number	:	801-263-7101
Fax Number	:

Provider Business Practice Location Address
First Line	:	4460 SOUTH HIGHLAND DRIVE
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84124-3503
Country	:	US
Telephone Number	:	801-263-7101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2018
Last Update Date	:	03/19/2018

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