Provider Demographics
NPI:1184657629
Name:DEPARTMENTN OF VETERANS AFFAIRS MEDICAL CENTER
Entity Type:Organization
Organization Name:DEPARTMENTN OF VETERANS AFFAIRS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:EDLEFSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:801-584-1242
Mailing Address - Street 1:1348 LAIRD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1935
Mailing Address - Country:US
Mailing Address - Phone:801-583-0231
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-584-1242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5877740-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty