Provider Demographics
NPI:1295855914
Name:NIGHT LIGHT PEDIATRICS LLC
Entity Type:Organization
Organization Name:NIGHT LIGHT PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:TWIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-628-8034
Mailing Address - Street 1:1240 E 100 S STE 14
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-3005
Mailing Address - Country:US
Mailing Address - Phone:435-628-8034
Mailing Address - Fax:
Practice Address - Street 1:1240 E 100 S STE 14
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-3005
Practice Address - Country:US
Practice Address - Phone:435-628-8034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT88-178110-12052080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT09165Medicaid