Provider Demographics
NPI:1295826865
Name:SOUTHERN UTAH UNIVERSITY
Entity Type:Organization
Organization Name:SOUTHERN UTAH UNIVERSITY
Other - Org Name:COMMUNITY & FAMILY HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERGEANIA
Authorized Official - Middle Name:P
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-586-6070
Mailing Address - Street 1:PO BOX 142001
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84114-2001
Mailing Address - Country:US
Mailing Address - Phone:435-856-6070
Mailing Address - Fax:435-586-5232
Practice Address - Street 1:2390 W HWY 56
Practice Address - Street 2:STE 1
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720
Practice Address - Country:US
Practice Address - Phone:435-586-6070
Practice Address - Fax:435-586-5232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8760000545631Medicaid
UTHT001413-001OtherPARTNER ID