Provider Demographics
NPI:1649561879
Name:WASATCH INFUSION
Entity Type:Organization
Organization Name:WASATCH INFUSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-577-7055
Mailing Address - Street 1:348 E 4500 S
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3906
Mailing Address - Country:US
Mailing Address - Phone:801-577-7055
Mailing Address - Fax:888-717-7578
Practice Address - Street 1:348 E 4500 S
Practice Address - Street 2:SUITE 220
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-3906
Practice Address - Country:US
Practice Address - Phone:801-577-7055
Practice Address - Fax:888-717-7578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT149834-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000074943Medicare PIN