Provider Demographics
NPI:1982429528
Name:STATE OF UTAH
Entity type:Organization
Organization Name:STATE OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-538-4330
Mailing Address - Street 1:195 N 1950 W
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:195 N 1950 W
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84116-3100
Practice Address - Country:US
Practice Address - Phone:801-538-4330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF UTAH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health