Provider Demographics
NPI:1164568101
Name:UNIVERSITY OF UTAH REDWOOD CENTER
Entity Type:Organization
Organization Name:UNIVERSITY OF UTAH REDWOOD CENTER
Other - Org Name:UHN REDWOOD
Other - Org Type:Other Name
Authorized Official - Title/Position:RN CLINICAL NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:LEANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KALFAOLU
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:801-213-9990
Mailing Address - Street 1:1525 W 2100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1401
Mailing Address - Country:US
Mailing Address - Phone:801-213-9990
Mailing Address - Fax:
Practice Address - Street 1:1525 W 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1401
Practice Address - Country:US
Practice Address - Phone:801-213-9990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2099403102261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========022Medicaid
UT=========022Medicaid