Provider Demographics
NPI:1679745467
Name:EXPRESS POX L.L.C.
Entity Type:Organization
Organization Name:EXPRESS POX L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:W
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRT
Authorized Official - Phone:801-721-0415
Mailing Address - Street 1:1896 E 5725 S
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5905
Mailing Address - Country:US
Mailing Address - Phone:801-721-0415
Mailing Address - Fax:801-479-7699
Practice Address - Street 1:1896 E 5725 S
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5905
Practice Address - Country:US
Practice Address - Phone:801-721-0415
Practice Address - Fax:801-479-7699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT103889-5701291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1912190091Medicare PIN