Provider Demographics
NPI:1679767834
Name:WESTERN INTERMOUNTAIN LITHOTRIPSY
Entity Type:Organization
Organization Name:WESTERN INTERMOUNTAIN LITHOTRIPSY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:KOOYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-757-6264
Mailing Address - Street 1:PO BOX 160515
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84016-0515
Mailing Address - Country:US
Mailing Address - Phone:801-779-4955
Mailing Address - Fax:801-774-8874
Practice Address - Street 1:862 GARDEN CIR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-6465
Practice Address - Country:US
Practice Address - Phone:801-964-1200
Practice Address - Fax:801-964-1344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2055261QL0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QL0400XAmbulatory Health Care FacilitiesClinic/CenterLithotripsy