Provider Demographics
NPI:1497899975
Name:SALT LAKE CITY V.A. LABORATORY
Entity Type:Organization
Organization Name:SALT LAKE CITY V.A. LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD MEDICAL TECHNOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-582-1565
Mailing Address - Street 1:11467 JORDAN BEND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8065
Mailing Address - Country:US
Mailing Address - Phone:
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:801-582-1565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT03567065291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory