Provider Demographics
NPI:1194978015
Name:CREEKSIDE MEDICAL EQUIPMENT & SUPPLIES
Entity type:Organization
Organization Name:CREEKSIDE MEDICAL EQUIPMENT & SUPPLIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SIONE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-673-5540
Mailing Address - Street 1:4232 S 500 W
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-1336
Mailing Address - Country:US
Mailing Address - Phone:801-263-1400
Mailing Address - Fax:801-263-9390
Practice Address - Street 1:376 SUNLAND DR
Practice Address - Street 2:SUITE 9
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5612
Practice Address - Country:US
Practice Address - Phone:435-673-5540
Practice Address - Fax:435-673-5052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5326946-1703332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870431335009Medicaid
UT6291800001Medicare NSC