Provider Demographics
NPI:1073811691
Name:CHIDESTER, ALEX
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:CHIDESTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KAEL
Other - Middle Name:
Other - Last Name:CHIDESTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:750 N 200 W
Mailing Address - Street 2:STE 300
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1677
Mailing Address - Country:US
Mailing Address - Phone:801-373-4760
Mailing Address - Fax:
Practice Address - Street 1:750 N 200 W
Practice Address - Street 2:STE 300
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1677
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator