Provider Demographics
NPI:1396804753
Name:SPECIALTY SALES & SERVICE A UTAH BUSINESS TRUST
Entity type:Organization
Organization Name:SPECIALTY SALES & SERVICE A UTAH BUSINESS TRUST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ZELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-679-1874
Mailing Address - Street 1:580 N MAIN ST STE 250D
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3994
Mailing Address - Country:US
Mailing Address - Phone:801-850-1330
Mailing Address - Fax:801-679-1875
Practice Address - Street 1:580 N MAIN ST STE 250D
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-3994
Practice Address - Country:US
Practice Address - Phone:801-679-1874
Practice Address - Fax:801-679-1875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT0918940001Medicare ID - Type Unspecified